Acute Myocarditis

Admit patients with suspected myocarditis who have acute heart failure, hemodynamic instability, syncope with suspected arrhythmia, sustained ventricular arrhythmia, high-grade atrioventricular block, or rising troponin with evolving ventricular dysfunction. Fulminant myocarditis presents with sudden severe diffuse myocardial inflammation and may progress to cardiogenic shock, often requiring intravenous inotropes or mechanical circulatory support (MCS). AHA Journals+2AHA JournalsRecognition and Initial Management of Fulminant MyocarditisAHA JournalsDiagnosis and Management of Myocarditis in ChildrenPubMedFulminant Myocarditis: When One Size Does Not Fit All – A Critical Review of the Literature - PMC

For cardiogenic shock, manage in an intensive care environment and involve advanced heart failure, interventional cardiology, electrophysiology, and cardiac surgery early. MCS is a bridge to recovery, diagnosis, or transplantation in patients whose perfusion cannot be maintained with pharmacologic support; the need for MCS should also accelerate planning for endomyocardial biopsy (EMB). AHA Journals+3AHA JournalsRecognition and Initial Management of Fulminant MyocarditisOxford Academica position statement of the European Society of Cardiology ...Oxford AcademicUpdate on myocarditis – what we know so far and where we may be ...PubMedFulminant Myocarditis: When One Size Does Not Fit All – A Critical Review of the Literature - PMC

Place patients with new atrioventricular block, ventricular tachycardia, or ventricular fibrillation on continuous telemetry. Avoid beta-blockers in clinically significant heart block; use antiarrhythmics cautiously when ventricular dysfunction is present because negative inotropy may worsen heart failure. Patients with heart block may require pacing. AHA Journals+1AHA JournalsDiagnosis and Management of Myocarditis in ChildrenPubMedViral Myocarditis - StatPearls - NCBI Bookshelf

Use the presenting syndrome to frame testing: acute chest pain, acute heart failure, new or recurrent unexplained arrhythmia, and cardiogenic shock are compatible clinical presentations. A suspected diagnosis is supported by at least one compatible presentation plus a diagnostic abnormality on noninvasive testing; asymptomatic patients require at least two diagnostic criteria. PubMed+1PubMedEvolution in the Diagnosis and Treatment of Myocarditis in Recent Years: State of the ArtPubMedAcute Myocarditis - StatPearls - NCBI Bookshelf

Obtain a 12-lead ECG, serial high-sensitivity troponin, and transthoracic echocardiography. Elevated troponin is a common trigger for suspicion, but chest pain with troponin elevation also requires evaluation for acute coronary syndrome before myocarditis is assigned as the explanation. Echocardiography defines ventricular function and detects clinically important heart-failure physiology, while strain imaging may add diagnostic information in selected suspected cases. Wiley+3WileyMultimodality imaging in acute myocarditisWileyAdvanced Computed Tomography and Magnetic ...WileyThe Utility of Strain Echocardiography in the Diagnosis ...PubMedAcute Myocarditis - StatPearls - NCBI Bookshelf

Cardiac MRI is the noninvasive test of choice for suspected myocarditis because it evaluates myocardial edema and injury. Apply the 2018 Lake Louise criteria, which have high diagnostic accuracy and improve diagnostic performance relative to original criteria. MRI should complement, not replace, urgent invasive evaluation in unstable patients. Oxford Academic+2Oxford AcademicImmune checkpoint inhibitor-related myocarditis: an illustrative ...WileyAssessing the Accuracy of Cine Post‐Contrast Cardiac ...pubs rsnaComparison of Original and 2018 Lake Louise Criteria for ...

Ask specifically about recent viral illness, autoimmune disease, new cancer immunotherapy, vaccination, cardiotoxic medication exposure, travel or epidemiologic risk, and systemic allergic or eosinophilic features. Viral infection is the most frequent cause in the United States and other developed countries, but myocarditis also follows autoimmune disease, vaccination, and cancer therapy. ScienceDirect+1ScienceDirectModeling immune checkpoint inhibitor associated ...PubMedViral Myocarditis - StatPearls - NCBI Bookshelf

Immune checkpoint inhibitor (ICI)-associated myocarditis is rare but potentially fatal. In a patient receiving cancer immunotherapy who develops troponin elevation, conduction disease, ventricular arrhythmia, heart failure, or compatible cardiac MRI findings, treat ICI exposure as a high-priority etiologic clue and coordinate urgent cardio-oncology evaluation; Lake Louise criteria can support MRI diagnosis in this setting. BMJ+1BMJMyocarditis and look-alikes: when the diagnosis mattersOxford AcademicImmune checkpoint inhibitor-related myocarditis: an illustrative ...

Biopsy-directed treatment is most consequential when EMB identifies eosinophilic myocarditis, giant cell myocarditis, cardiac sarcoidosis, or autoimmune myocarditis. Maintenance immunosuppression is often required for autoimmune disease-associated myocarditis and for sarcoid, giant cell, or eosinophilic myocarditis; empiric intravenous corticosteroids are described for fulminant myocarditis or myocarditis causing acute heart failure, high-grade AV block, or ventricular arrhythmias. PubMed+1PubMedAdvances in myocarditis management in the light of the latest research and recent guidelines of the European Society of CardiologyPubMedMyocarditis: Diagnostic Modalities and Treatment Options

For myocarditis with heart failure or ventricular dysfunction, initiate and titrate guideline-directed medical therapy as tolerated, using diuretics for congestion and standard heart-failure therapy for persistent systolic dysfunction. Acute myocarditis presenting as dilated cardiomyopathy is managed primarily with an optimal heart-failure regimen. AHA Journals+2AHA JournalsManagement of Myocarditis-Related Cardiomyopathy in ...Oxford AcademicThe management of myocarditis - Oxford AcademicPubMedViral Myocarditis - StatPearls - NCBI Bookshelf

Manage arrhythmias according to clinical stability and ventricular function, recognizing that antiarrhythmic drugs can worsen heart failure through negative inotropy. Maintain monitoring for ventricular arrhythmias and conduction deterioration during the acute phase; use pacing when clinically significant heart block requires it. AHA Journals+2AHA JournalsDiagnosis and Management of Myocarditis in ChildrenPubMedMyocarditis: Diagnostic Modalities and Treatment OptionsPubMedViral Myocarditis - StatPearls - NCBI Bookshelf

Restrict physical activity until symptoms resolve and inflammatory markers normalize. At least 1 month may be needed for clinical remission, but return to sports should generally wait 3 to 6 months and requires absence of symptoms and arrhythmias, no ongoing inflammation, and normal LV systolic function. PubMed+1PubMedEvolution in the Diagnosis and Treatment of Myocarditis in Recent Years: State of the ArtPubMedMyocarditis: Diagnostic Modalities and Treatment Options