From the Guidelines
Viral myocarditis is primarily caused by viral infections, and its management should focus on supportive care, with hospitalization recommended for patients with definite myocarditis, ideally at an advanced heart failure center, as stated in the 2022 ACC Expert Consensus Decision Pathway 1. The most common viral causes of myocarditis include coxsackieviruses, adenoviruses, parvovirus B19, herpes viruses, and influenza viruses. Some key points to consider in the management of viral myocarditis include:
- Restricting physical activity during the acute phase to reduce cardiac workload and prevent complications
- Treatment with standard heart failure medications, such as ACE inhibitors, beta-blockers, and diuretics, if fluid retention is present
- Avoiding nonsteroidal anti-inflammatory drugs, as they may worsen inflammation
- Considering antiviral medications in specific cases, such as herpes virus infections
- Regular cardiac follow-up with echocardiograms to monitor recovery According to the 2022 ACC Expert Consensus Decision Pathway, patients with myocarditis and COVID-19 pneumonia with an ongoing need for supplemental oxygen should be treated with corticosteroids 1. Additionally, the use of intravenous corticosteroids may be considered in patients with suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or MIS-A, as this approach was associated with a favorable prognosis in a small series 1. Cardiovascular magnetic resonance (CMR) is also recommended in hemodynamically stable patients with suspected myocarditis, as it can noninvasively identify myocardial edema and provide a specific marker for acute inflammation, including its severity and localization 1. Overall, the management of viral myocarditis should prioritize supportive care, with a focus on reducing cardiac workload, preventing complications, and monitoring recovery, as outlined in the 2022 ACC Expert Consensus Decision Pathway 1.
From the Research
Causes of Viral Myocarditis
- Viral infections are the most common cause of infectious myocarditis, with coxsackievirus B being a prevalent cause 2
- Other viruses such as influenza A, COVID-19, human herpes virus 6, and parvovirus B19 can also cause myocarditis 3, 4, 5
- The exact mechanism of viral-induced damage to myocytes is unknown, but likely involves immune-mediated and direct viral cytotoxicity 2
- Myocarditis can occur secondary to direct cardiac invasion with the virus or to intense cytokine storm 3
Management of Viral Myocarditis
- Treatment options include immunosuppressive agents, intravenous immunoglobulin (IVIG), antiviral agents, and natural products such as Astragalus membranaceus and Ardisia chinensis 2
- Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis 3
- Corticosteroids may be avoided during the early phase of viral replication, but can be beneficial in hospitalized, critically ill patients 3
- Statins may be beneficial to shorten the course of the disease and decrease mortality 3
- Milrinone and methylprednisolone have been used effectively in the treatment of SARS-CoV-2 related fulminant myocarditis 5