NEWS Myocarditis is a serious inflammation of the heart muscle that can hit young, healthy people hard—and without warning. In the worst cases, it can lead to heart failure or sudden cardiac death. Researcher Anne Tuiskunen Bäck is working to close key knowledge gaps in diagnostics, risk assessment, and follow-up of patients.
Researcher Anne Tuiskunen Bäck and her PhD Amina Hayat.
ImageIngrid Söderberghit is very important to obtain new knowledge
“It is very important to obtain new knowledge, so that we can more easily make the correct diagnosis and find risk groups. Most people with myocarditis recover on their own, but some patients develop heart complications. If we can identify these patients early, we could implement preventive measures,” says Anne Tuiskunen Bäck, a specialist in cardiology at Norrland University Hospital and a researcher at Umeå University.
You often hear that you should avoid exercise when you have a cold – and there is a good reason: the risk of myocarditis. In the Western world, myocarditis is most often caused by viruses, but bacteria, fungi, parasites, side effects of certain cancer drugs or autoimmune diseases can also be behind it. In the disease, the immune system overreacts and attacks the heart muscle, which can impair the heart's ability to pump blood around the body.
“No specific treatments exist, and in most cases, the disease is mild and transient. We usually let go of patients completely when the myocarditis appears to have healed and all tests have normalized. We urge them to avoid physical activity for a couple of months, which can be difficult, especially for younger people, to follow,” says Anne Tuiskunen Bäck.
However, myocarditis can cause long-term complications and, in some cases, become chronic if the inflammation does not heal completely. Over time, the heart loses its elasticity and enlarges, as the heart wall thins when heart muscle cells are replaced by scar tissue. In the most severe cases, this can lead to terminal heart failure, where a heart transplant becomes necessary to survive. Today, there is a lack of knowledge about how to identify early on which patients are at risk of being affected.
Patients who come to the hospital experience symptoms such as unexplained chest pain, shortness of breath and palpitations.
ImageJohnér bildbyråAnne Tuiskunen Bäck got the idea for her research project two years ago when her clinic director asked her to look through the clinical management plan for myocarditis patients, which is based on the European Society of Cardiology guidelines.
“I was surprised; the guidelines were from 2013! Unlike the guidelines for myocardial infarction, which are updated every five years. The lack of updated guidelines is due to the absence of large clinical studies on myocarditis,” says Anne Tuiskunen Bäck.
In the scientific literature, Anne saw a clear lack of research on how infections affect myocarditis. She also reacted to the lack of communication between virology and cardiology – two fields that would benefit from collaborating more. That is where the interest was sparked.
“I got involved in how we could improve the routines for long-term follow-up, to identify patients at risk of developing severe cardiac complications and also to look for better tools for diagnosing myocarditis,” says Anne.
Last year, Anne Tuiskunen Bäck began the extensive work of preparing the clinical study – a process that requires careful planning and extensive administration. Since the study involves data from humans, approval is required from the Swedish Ethics Review Authority, an authority for all clinical research in Sweden. Anne eventually received permission to follow newly diagnosed patients until the year 2050 and previous cases of myocarditis in Västerbotten since 2009.
The study is now operating at a high level of activity. The newly diagnosed patients (the acute patient group) submit repeated samples during the days they are hospitalized and then at return visits. The other patient group who has had myocarditis previously submits a blood sample via their local health care centre.
“We will follow each patient for a really long time through medical records regarding their heart health and compare with what we see in their samples to find new diagnostic and risk markers.”
Anne Tuiskunen Bäck has recently been awarded 500,000 kronor from the Norrländska Hjärtfonden for the research project, an addition that gives the work a new boost. She has recruited Amina Hayat, a specialist in cardiology, as a doctoral student. Amina is responsible, among other things, for contacting new participants in the study. In the Autumn, the research group will be further strengthened when two postdoctoral fellows join to work on the project.
“The turnout of participants is overwhelming. One 20-year-old even said that it felt like a privilege to be part of the study, that makes it extra fun!”
The patients being followed are asked to provide blood samples. ImageMattias Pettersson
It is difficult to diagnose suspected myocarditis. The doctor performs a physical examination and looks at the patient's symptoms, takes blood samples, an ECG, a cardiac ultrasound and performs an MRI scan of the heart. Early biopsy – a tissue sample from the heart – is the most reliable way to make a diagnosis but is also fraught with several limitations and uncertainties.
“For this reason, we do it extremely rarely. If the patient is not terminally ill with their heart disease, there is very little benefit in retrieving a biopsy from the heart. That is the reasoning.”
As a result, the diagnosis is often based on a probability assessment rather than a definitive conclusion. The fact that many cases probably also go under the radar is another reason for the lack of reliable statistics on how many people are affected by myocarditis in Sweden each year.
The second part of the project focuses on finding new biomarkers for diagnosing myocarditis. Anne Tuiskunen Bäck is investigating whether a blood test can replace tissue tests. She and her colleagues analyse lab samples from the patients, including using metagenomics to find out which virus is involved, and also map the patients' genome to see if genetic factors increase the risk. In collaboration with other research groups, they will study the immune response and metabolomics of the patients at a later stage.
This is a typical example of a translational project, which means that basic research solves questions raised in the clinic. In this way, Anne Tuiskunen Bäck uses both her knowledge in virology and her clinical competence as a medical doctor. The research is also interdisciplinary and spans virology, cardiology and genetics.
The study is extensive. It involves several clinics, many colleagues and patients of all ages, from infants to the elderly. There are also discussions about scaling up the study to other hospitals in Sweden.
Cardiology is a dynamic and research-intensive field that naturally interacts with virology, notes Anne Tuiskunen Bäck.
“It is both exciting and fun to combine two fields. Having one foot in virology and one in cardiology works great – and feels innovative.”
World Heart Day is celebrated globally on September 29th each year to raise awareness of cardiovascular diseases and promote good heart health through lifestyle changes. The Norrländska hjärtfonden invites Anne Tuiskunen Bäck to present her study on myocarditis at Folkets hus in Umeå.
