Age-associated clinical patterns in paediatric myocarditis: left ventricular function as the key early risk stratifier

Abstract Background and Aims In myocarditis, early identification of high-risk patients is essential, robust prognostic markers are lacking. We aimed to identify early clinical risk stratifier at index hospitalization for major adverse cardiovascular events (MACE). Methods We analysed 725 paediatric patients with possible/definite myocarditis enrolled in the prospective multicentre MYKKE registry (2013–2024). MACE included mechanical circulatory support (MCS), heart transplantation, or death during initial admission. Model-based recursive partitioning (MOB) and bootstrap-based logistic regression with multiple imputation were applied for risk stratifier selection out of 20 baseline variables. The model was externally validated in the Swedish SWEDCON- cohort (n = 243). Discrimination was assessed by the area under the curve (AUC). Results Among 725 patients (median age 14.3 years [IQR 4.0–16.4]; 33% female), 88 (12.2%) experienced MACE (MCS 10.9%, transplantation 4.3%, death 2.2%). MOB identified left ventricular ejection fraction (LVEF) ≤ 39% as the only stable risk stratifier, delineating a “heart failure type” in younger children (1.9 years; LVEF 24%), and a “chest pain type” in adolescents with preserved LVEF (15.6 years; LVEF 59%). LVEF was confirmed as the sole robust risk stratifier (OR per 1% increase: 0.90 ; 95% CI 0.881-0.917; p < 0.01; AUC 0.90, 95% CI 0.896–0.903). In SWEDCON (7.4% MACE), discrimination was maintained (AUC 0.894, 95% CI 0.80–0.991). Conclusion Reduced LVEF at presentation was the only reproducible and externally validated risk stratifier of MACE during index hospitalization. Two age-associated clinical patterns were observed: a high-risk “heart failure type” in younger children and low-risk “chest pain type” in adolescents.

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Publication Details

Journal
ESC Heart Failure
Published
2026-10-14
DOI
https://doi.org/10.1093/eschf/xvag259
Primary Topic
Viral Infections and Immunology Research
Type
article
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article

Age-associated clinical patterns in paediatric myocarditis: left ventricular function as the key early risk stratifier

Nele Rolfs, Eva Gatzweiler, Ulrike Herberg, Johannes Weickmann et al.
ESC Heart Failure
Viral Infections and Immunology Research
article

Age-associated clinical patterns in paediatric myocarditis: left ventricular function as the key early risk stratifier

Nele Rolfs, Eva Gatzweiler, Ulrike Herberg, Johannes Weickmann, Michael Kaestner, Jennifer Kramp, Walter Knirsch, Inga Voges, Bardo Wannenmacher, Katja Reineker, W. Frede, Jens Böhmer, Kerstin Gummel, André Rudolph, Tania Garfias‐Veitl, G. Tarusinov, Thomas Pickardt, Franziska Seidel, Tim Friede, Cynthia Huber, G. Wiegand, Daniel Messroghli, Bernd Opgen‐Rhein, Stephan Schubert, Axel Rentzsch, D. Kiski, K. Papakostas, Felix Anderheiden, Martin Boehne, Gunter Kerst, Dorothée Böcker, T. Hecht, Bettina Ruf, Marcus Fischer, Assunta Schiebel, Eicke Schwanzkopf
article en

Abstract

Abstract Background and Aims In myocarditis, early identification of high-risk patients is essential, robust prognostic markers are lacking. We aimed to identify early clinical risk stratifier at index hospitalization for major adverse cardiovascular events (MACE). Methods We analysed 725 paediatric patients with possible/definite myocarditis enrolled in the prospective multicentre MYKKE registry (2013–2024). MACE included mechanical circulatory support (MCS), heart transplantation, or death during initial admission. Model-based recursive partitioning (MOB) and bootstrap-based logistic regression with multiple imputation were applied for risk stratifier selection out of 20 baseline variables. The model was externally validated in the Swedish SWEDCON- cohort (n = 243). Discrimination was assessed by the area under the curve (AUC). Results Among 725 patients (median age 14.3 years [IQR 4.0–16.4]; 33% female), 88 (12.2%) experienced MACE (MCS 10.9%, transplantation 4.3%, death 2.2%). MOB identified left ventricular ejection fraction (LVEF) ≤ 39% as the only stable risk stratifier, delineating a “heart failure type” in younger children (1.9 years; LVEF 24%), and a “chest pain type” in adolescents with preserved LVEF (15.6 years; LVEF 59%). LVEF was confirmed as the sole robust risk stratifier (OR per 1% increase: 0.90 ; 95% CI 0.881-0.917; p < 0.01; AUC 0.90, 95% CI 0.896–0.903). In SWEDCON (7.4% MACE), discrimination was maintained (AUC 0.894, 95% CI 0.80–0.991). Conclusion Reduced LVEF at presentation was the only reproducible and externally validated risk stratifier of MACE during index hospitalization. Two age-associated clinical patterns were observed: a high-risk “heart failure type” in younger children and low-risk “chest pain type” in adolescents.

ESC Heart Failure
Karolinska University Hospital (SE), Universität Hamburg (DE), Max Delbrück Center (DE), Heidelberg University (DE), Universitätsklinikum Gießen und Marburg (DE), University Hospital Bonn (DE), Heart and Diabetes Center North Rhine-Westphalia (DE), Sahlgrenska University Hospital (SE), University Hospital Heidelberg (DE), Karolinska Institutet (SE), LMU Klinikum (DE), Medizinische Hochschule Hannover (DE), Humboldt-Universität zu Berlin (DE), Universitätsklinikum Erlangen (DE), University Hospital Münster (DE), Deutsches Herzzentrum der Charité (DE), University Medical Center Hamburg-Eppendorf (DE), University Hospital Schleswig-Holstein (DE), Leipzig Heart Institute (DE), Universitätsmedizin Göttingen (DE), Klinikum Frankfurt Höchst (DE), München Klinik (DE), University Children's Hospital Tübingen (DE), German Centre for Cardiovascular Research (DE), University Children's Hospital Zurich (CH), Universitäts-Herzzentrum Freiburg-Bad Krozingen (DE), BG Klinikum Duisburg (DE), Medizinische Universität Lausitz - Carl Thiem (DE), Giessen School of Theology (DE), Deutsches Herzzentrum München (DE), University Hospital in Halle (DE), Klinikum Bremen-Mitte (DE), University Hospital Cologne (DE), University Hospital Ulm (DE), Klinikum Stuttgart (DE), University of Göttingen (DE), Charité - Universitätsmedizin Berlin (DE), University of Tübingen (DE), Ludwig-Maximilians-Universität München (DE), University of Gothenburg (SE), RWTH Aachen University (DE), Saarland University (DE), University of Lübeck (DE)
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Viral Infections and Immunology Research
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