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摘要: 《2023年JCS心肌炎诊断和治疗指南》在心肌炎的定义和分类、流行病学、病理生理学、诊断标准、诊断流程、治疗及管理等多个方面进行了全新诠释，为临床医师提供了更贴合临床实际的心肌炎诊断和治疗建议。鉴于我国近期无心肌炎相关指导性文件发布，本文将结合国内外最新心肌炎研究进展，对该指南要点进行全面解读，以期为我国心肌炎临床诊疗提供参考。Abstract: JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis offers a new perspective on the definition, classification, epidemiology, pathophysiology, diagnosis, diagnostic, treatment and management of myocarditis. It also provides recommendations to clinicians on the diagnosis and treatment of myocarditis which are more suitable for clinical practice. Given that no myocarditis guidance document has recently been issued in China, this article provides a comprehensive interpretation of the key points of this guideline combined with the latest research, so as to provide reference for the diagnosis and treatment of myocarditis in our country.
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Key words:
- myocarditis /
- endomyocardial biopsy /
- classification /
- treatment
作者贡献：张松负责论文撰写、图表绘制；邱露虹、刘颖娴负责文献收集、整理；徐希奇负责论文修订。利益冲突：所有作者均声明不存在利益冲突 -
图 1 《2023年JCS心肌炎诊断和治疗指南》推荐的急性心肌炎诊断流程
BNP(brain natriuretic peptide)：B型钠尿肽；CK-MB(creatine kinase-MB)：肌酸肌酶同工酶MB型；CTA(computed tomography angiography)：电子计算机断层扫描血管造影；ECG(electrocardiogram)：心电图；Echo(echocardiography)：心脏超声；ECV(extracellular volume)：细胞外容积；MINOCA(myocardial infarction with no obstructive coronary atherosclerosis)：非冠状动脉阻塞性心肌梗死；NT-proBNP(N terminal pro B type natriuretic peptide)：N末端B型钠尿肽前体；CMR、EMB、cTn：同表 1
Figure 1. Diagnostic algorithm for acute myocarditis recommended by JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis
表 1 《2023年JCS心肌炎诊断和治疗指南》对不同临床分型心肌炎的定义
Table 1. Definitions of myocarditis with different clinical features by JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis
临床分型 定义 心肌炎症细胞浸润 心肌细胞损伤(变性/坏死) 急性心肌炎 (1)起病时间＜30 d，组织病理学特征为炎症细胞浸润和心肌细胞损伤(心肌细胞变性/坏死伴邻近炎症细胞浸润)
(2)当EMB不可行时，根据临床表现和症状进行诊断：①血清超敏cTn升高；②CMR提示心肌水肿+ + 慢性活动性心肌炎 (1)起病时间≥30 d，组织病理学特征为炎症细胞浸润和心肌细胞损伤(心肌细胞变性/坏死伴邻近炎症细胞浸润)
(2)即使组织病理学未见心肌细胞损伤，以下任一表现均可提示慢性活动性心肌炎的存在：①持续的血清超敏cTn升高；②CD3+T淋巴细胞≥24个/mm2(5.8个/高倍视野)；③心肌组织Tenascin C(4C8)染色阳性+ + 慢性心肌炎 起病时间≥30 d，组织病理学特征为炎症细胞浸润，不伴心肌细胞损伤(心肌细胞变性/坏死伴邻近炎症细胞浸润)，可视为急性心肌炎向慢性炎症性心肌病过渡阶段 + - 慢性炎症性心肌病 (1)起病时间≥30 d，室壁运动减低
(2)组织病理学特征为心肌间质纤维化伴心肌细胞异常(包括细胞大小不一)和炎症细胞浸润(淋巴细胞≥14个/mm2和CD3+ T淋巴细胞≥7个/mm2)，不伴心肌细胞损伤(心肌细胞变性/坏死伴邻近炎症细胞浸润)+ - 炎症性扩张型心肌病 (1)为扩张型心肌病的亚型，概念上属于慢性炎症性心肌病
(2)组织病理学特征为炎症细胞浸润，不伴心肌细胞损伤(心肌细胞变性/坏死伴邻近炎症细胞浸润)+ - EMB(endomyocardial biopsy)：心内膜心肌活检；cTn(cardiac troponin)：心肌肌钙蛋白；CMR(cardiovascular magnetic resonance)：心脏磁共振 
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表 2 《2023年JCS心肌炎诊断和治疗指南》推荐心肌炎行EMB的情形
Table 2. Class of endomyocardial biopsy in myocarditis recommended by JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis
EMB适应证 推荐强度 证据等级 对伴严重心力衰竭或心源性休克的疑诊急性心肌炎患者，若具备EMB条件应行EMB Ⅰ C 对伴急性心力衰竭、室性心律失常或高度房室传导阻滞的疑诊急性心肌炎患者，若具备EMB条件应行EMB Ⅰ C 对伴外周嗜酸性粒细胞增多的疑诊急性心肌炎患者，可考虑行EMB Ⅱa C 对疑诊免疫检查点抑制剂相关心肌炎患者，可考虑行EMB Ⅱa C 除上述病例外，若疑诊急性心肌炎时，应考虑行EMB Ⅱb C 对于疑诊慢性活动性心肌炎或慢性炎症性心肌病患者，可考虑行EMB Ⅱa C EMB：同表 1
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