From the Guidelines
Corticosteroids should be used in the treatment of myocarditis in patients with COVID-19 pneumonia and ongoing need for supplemental oxygen, as well as in those with suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or MIS-A, a hyper-inflammatory state with acute heart failure and/or cardiogenic shock. The use of corticosteroids in myocarditis is guided by the specific clinical context and the presence of certain conditions. According to the 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults 1, patients with myocarditis and COVID-19 pneumonia who require supplemental oxygen should be treated with corticosteroids. Additionally, corticosteroids may be considered in patients with suspected or confirmed COVID-19 myocarditis who have hemodynamic compromise or MIS-A, as this approach has been associated with a favorable prognosis. Some key points to consider when using corticosteroids in myocarditis include:
- The decision to use corticosteroids should be individualized based on the specific etiology of myocarditis, severity of inflammation, and the patient's overall clinical condition.
- Patients on corticosteroids require monitoring for side effects, including hyperglycemia, hypertension, mood changes, and increased infection risk.
- Treatment should be guided by a cardiologist, often in consultation with rheumatology.
- The use of corticosteroids in myocarditis is not without controversy, and the potential benefits and risks must be carefully weighed in each individual case. It's also important to note that the use of corticosteroids in myocarditis is not universally recommended, and the approach may vary depending on the specific clinical context and the presence of certain conditions, as outlined in other studies 1. However, the most recent and highest quality study 1 provides the best guidance on the use of corticosteroids in myocarditis.
From the Research
Role of Corticosteroids in Myocarditis Treatment
- Corticosteroids are used to treat specific forms of myocarditis, such as eosinophilic or giant cell infiltrations, or myocarditis caused by systemic autoimmune disorders 2.
- The use of corticosteroids for viral myocarditis is controversial, with some studies suggesting potential benefits in improving cardiac function, but the evidence is limited by low-quality and small-sized trials 3.
- Corticosteroids may be effective in treating recurrent myocarditis, as seen in a case report where a patient with recurrent Coxsackie B myocarditis showed rapid improvement in symptoms after treatment with intravenous immunoglobulin and a steroid taper 4.
- In cases of immune checkpoint inhibitor-associated myocarditis, corticosteroids are recommended as first-line treatment, but some patients may be resistant to corticosteroid treatment, and alternative treatments such as tofacitinib may be effective 5.
- Corticosteroids play a crucial role in treating cardiac complications of Duchenne muscular dystrophy, and switching between steroid classes or discontinuing steroids can lead to acute myocardial inflammation or myocarditis 6.
Specific Indications for Corticosteroid Use
- Eosinophilic or giant cell myocardial infiltrations 2
- Systemic autoimmune disorders 2
- Recurrent myocarditis 4
- Immune checkpoint inhibitor-associated myocarditis 5
- Duchenne muscular dystrophy-related cardiomyopathy 6
Limitations and Controversies
- Limited evidence for the use of corticosteroids in viral myocarditis 3
- Controversy surrounding the optimal dose and duration of corticosteroid treatment 3
- Potential for corticosteroid resistance in immune checkpoint inhibitor-associated myocarditis 5
- Risks associated with switching between steroid classes or discontinuing steroids in Duchenne muscular dystrophy 6