What is the treatment for myocardial involvement in Dengue Fever?

Treatment of Myocardial Involvement in Dengue Fever

For patients with myocardial involvement in dengue fever, treatment should focus on supportive care with careful fluid management, cardiac monitoring, and consideration of anti-inflammatory therapy for those with significant myocarditis. 1

Initial Assessment and Management

• Perform ECG, cardiac troponin measurement, and echocardiogram to assess ventricular function and wall motion abnormalities in dengue patients with suspected cardiac involvement 2
• Cardiac MRI is recommended for hemodynamically stable patients to confirm myocardial inflammation and exclude other causes 1, 2
• Hospitalize patients with definite myocarditis, ideally at an advanced heart failure center 1
• Patients with fulminant course (cardiogenic shock, sustained ventricular arrhythmias, advanced AV block) should be managed at centers with expertise in advanced heart failure and mechanical circulatory support 1

Fluid Management

• Administer an initial fluid bolus of 20 mL/kg for dengue shock syndrome with subsequent patient reassessment 1
• Careful fluid management is critical as both inadequate and excessive fluid administration can worsen outcomes in dengue patients with myocardial involvement 1, 3
• Frequent reassessment after fluid administration is essential to detect deterioration at an early stage 1

Pharmacological Management

• For patients with associated pericardial involvement, nonsteroidal anti-inflammatory drugs may help alleviate chest pain and inflammation 1
• Low-dose colchicine or prednisone may be added for persistent chest pain, with a plan to taper based on symptoms and clinical findings 1
• Consider low-dose aldosterone system inhibitors empirically in patients with mildly reduced left ventricular systolic function and stable hemodynamics 1
• Beta-blockers may be helpful in patients with supraventricular arrhythmias if hemodynamically stable, but can precipitate cardiogenic shock in patients with compromised cardiac function 1
• Intravenous corticosteroids may be considered in patients with hemodynamic compromise or multisystem inflammatory state with acute heart failure/cardiogenic shock 1

Monitoring and Follow-up

• Perform close monitoring for worrisome symptoms or signs (shortness of breath, syncope, edema) 1
• Consider follow-up testing (ECG, echocardiogram, ambulatory rhythm monitor, CMR) 3-6 months after presentation, particularly in those with ongoing cardiac symptoms 1
• Avoid strenuous physical activity for 3-6 months in patients diagnosed with myocarditis 1
• Initiate guideline-directed medical therapy for heart failure before discharge and titrate as appropriate in the outpatient setting for patients who developed heart failure 1

Special Considerations

• Cardiac involvement in dengue is often transient but may be associated with significant morbidity and mortality 3
• Multiple mechanisms contribute to myocardial dysfunction in dengue, including direct viral invasion, immune mechanisms, electrolyte imbalance, and hypotension 3
• ECG abnormalities to monitor for include sinus bradycardia, nonspecific ST-T changes, ST depression, and T-wave inversion 4
• Mechanical sequelae may include left ventricular systolic dysfunction and myocarditis 4
• Pericardial involvement may present as pericarditis, pericardial effusion, or rarely pericardial tamponade 4

Management Algorithm for Myocardial Involvement in Dengue

1. Identify suspected myocardial involvement (chest pain, dyspnea, arrhythmias, hypotension) 2, 5
2. Perform initial cardiac evaluation (ECG, troponin, echocardiogram) 2
3. Stratify risk based on hemodynamic stability and cardiac findings 1
4. For stable patients: supportive care, careful fluid management, cardiac monitoring 1, 3
5. For unstable patients: transfer to advanced heart failure center, consider mechanical support if needed 1
6. Implement anti-inflammatory therapy for significant myocarditis or pericarditis 1
7. Monitor for improvement and adjust therapy accordingly 1
8. Plan for follow-up cardiac evaluation after recovery 1