Assessment of acute myocarditis by cardiac magnetic resonance imaging: Comparison of qualitative and quantitative analysis methods

  • Massimo Imbriaco
  • Carmela Nappi
  • Marta Puglia
  • Marco De Giorgi
  • Serena Dell’Aversana
  • Renato Cuocolo
  • Andrea Ponsiglione
  • Igino De Giorgi
  • Maria Vincenza Polito
  • Michele Klain
  • Federico Piscione
  • Leonardo Pace
  • Alberto Cuocolo
Original Article



To compare cardiac magnetic resonance (CMR) qualitative and quantitative analysis methods for the noninvasive assessment of myocardial inflammation in patients with suspected acute myocarditis (AM).


A total of 61 patients with suspected AM underwent coronary angiography and CMR. Qualitative analysis was performed applying Lake-Louise Criteria (LLC), followed by quantitative analysis based on the evaluation of edema ratio (ER) and global relative enhancement (RE). Diagnostic performance was assessed for each method by measuring the area under the curves (AUC) of the receiver operating characteristic analyses. The final diagnosis of AM was based on symptoms and signs suggestive of cardiac disease, evidence of myocardial injury as defined by electrocardiogram changes, elevated troponin I, exclusion of coronary artery disease by coronary angiography, and clinical and echocardiographic follow-up at 3 months after admission to the chest pain unit.


In all patients, coronary angiography did not show significant coronary artery stenosis. Troponin I levels and creatine kinase were higher in patients with AM compared to those without (both P < .001). There were no significant differences among LLC, T2-weighted short inversion time inversion recovery (STIR) sequences, early (EGE), and late (LGE) gadolinium-enhancement sequences for diagnosis of AM. The AUC for qualitative (T2-weighted STIR 0.92, EGE 0.87 and LGE 0.88) and quantitative (ER 0.89 and global RE 0.80) analyses were also similar.


Qualitative and quantitative CMR analysis methods show similar diagnostic accuracy for the diagnosis of AM. These findings suggest that a simplified approach using a shortened CMR protocol including only T2-weighted STIR sequences might be useful to rule out AM in patients with acute coronary syndrome and normal coronary angiography.


Myocarditis cardiac imaging magnetic resonance imaging 



Acute myocarditis


Cardiac magnetic resonance


Lake-Louise Criteria


Early gadolinium-enhancement


Late gadolinium-enhancement


Short time inversion recovery


Edema ratio


Relative enhancement


Region of interest


Area under the curve


Receiver operating characteristic



M. Imbriaco, C. Nappi, M. Puglia, M. De Giorgi, S. Dell’Aversana, R. Cuocolo, A. Ponsiglione, I. De Giorgi, M.V. Polito, M. Klain, F. Piscione, L. Pace, A. Cuocolo declare that they have no conflict of interest.

Supplementary material

12350_2017_1109_MOESM1_ESM.pptx (2.5 mb)
Supplementary material 1 (PPTX 2563 kb)


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Copyright information

© American Society of Nuclear Cardiology 2017

Authors and Affiliations

  • Massimo Imbriaco
    • 1
  • Carmela Nappi
    • 1
  • Marta Puglia
    • 1
  • Marco De Giorgi
    • 2
  • Serena Dell’Aversana
    • 1
  • Renato Cuocolo
    • 1
  • Andrea Ponsiglione
    • 1
  • Igino De Giorgi
    • 3
  • Maria Vincenza Polito
    • 2
  • Michele Klain
    • 1
  • Federico Piscione
    • 2
  • Leonardo Pace
    • 2
  • Alberto Cuocolo
    • 1
  1. 1.Department of Advanced Biomedical SciencesUniversity of Naples “Federico II”NaplesItaly
  2. 2.Department of Medicine and SurgeryUniversity of SalernoSalernoItaly
  3. 3.Department of Diagnostic Imaging and RadiotherapyA.O. San Giovanni di Dio e Ruggi d’AragonaSalernoItaly

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