What is the treatment for myocarditis?

From the Guidelines

Treatment for myocarditis should be based on the severity of the condition, with mild cases managed with rest, pain relievers, and restriction of physical activity, while more severe cases require hospitalization and targeted therapies such as corticosteroids, ACE inhibitors, and beta-blockers. According to the 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults 1, hospitalization is recommended for patients with definite myocarditis that is either mild or moderate in severity, ideally at an advanced heart failure center. Patients with fulminant myocarditis should be managed at centers with expertise in advanced heart failure, mechanical circulatory support, and other advanced therapies.

Some key considerations in the treatment of myocarditis include:

• The use of corticosteroids in patients with myocarditis and COVID-19 pneumonia with ongoing need for supplemental oxygen 1
• The consideration of intravenous corticosteroids in those with suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or MIS-A 1
• The use of guideline-directed medical therapy for heart failure, such as ACE inhibitors and beta-blockers, to manage heart failure symptoms 1
• The avoidance of strenuous physical activity for 3-6 months to allow the heart muscle to heal 1

It is also important to note that treatment of myocarditis should be individualized based on the underlying cause and severity of the condition. As stated in the 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults 1, cardiology consultation is recommended for those with a rising cTn and/or ECG or echocardiographic abnormalities concerning for myocarditis. Additionally, CMR is recommended in hemodynamically stable patients with suspected myocarditis to confirm the diagnosis and assess the extent of ventricular dysfunction and inflammation 1.

Overall, the goal of treatment for myocarditis is to reduce inflammation, support cardiac function, and address the underlying cause while allowing the heart muscle to heal, with the ultimate goal of improving morbidity, mortality, and quality of life outcomes.

From the Research

Myocarditis Treatment Overview

• Myocarditis is a potentially fatal condition that requires prompt diagnosis and treatment 2.
• Treatment is primarily focused on respiratory and hemodynamic support, with initial hemodynamic management including vasopressors and inotropes 2.
• More severe cases may require an intra-aortic balloon pump, extracorporeal membrane oxygenation, or a ventricular assist device 2, 3.

Treatment Approaches

• Supportive care is the first-line therapy, with treatment depending on acuity, severity, clinical presentation, and etiology 3.
• Immunosuppression, such as corticosteroids, may be appropriate for patients with myocarditis characterized by eosinophilic or giant cell myocardial infiltrations or due to systemic autoimmune disorders 3, 4.
• Intravenous immunoglobulin (IVIG) may be beneficial for fulminant, acute, and chronic autoreactive myocarditis, as well as viral cardiomyopathy and myocarditis 4.

Diagnostic Considerations

• Diagnosis of myocarditis can be suggested by presenting symptoms, elevated biomarkers, electrocardiographic changes, and echocardiographic wall motion abnormalities or wall thickening 3, 5.
• Cardiac magnetic resonance imaging or endomyocardial biopsy may be required for definitive diagnosis 3, 5, 6.
• Noninvasive and invasive biomarkers, including endomyocardial biopsy and polymerase chain reaction on cardiotropic agents, can contribute to the clinical work-up of the syndrome 4.

Specific Treatment Options

• Nonsteroidal anti-inflammatory drugs should be avoided in the treatment of myocarditis 2.
• IVIG treatment can frequently resolve inflammation in viral cardiomyopathy and myocarditis, but the eradication of parvovirus B19 and human herpesvirus-6 is still a challenge 4.
• Novel approaches to treatment are being explored, including the use of cardiac magnetic resonance imaging and endomyocardial biopsy to guide treatment decisions 5.