Treatment of COVID-19 Myocarditis
All patients with definite COVID-19 myocarditis require hospitalization at an advanced heart failure center, with fulminant cases managed at centers with mechanical circulatory support and transplant capabilities. 1, 2
Initial Diagnostic Workup
When cardiac involvement is suspected in COVID-19 patients, obtain:
- ECG to identify conduction abnormalities or ST-segment changes 1
- High-sensitivity cardiac troponin (serial measurements if initially elevated) 1, 2
- Transthoracic echocardiography to assess ventricular function and wall motion abnormalities 1, 3
- Cardiology consultation for rising troponin or abnormal ECG/echo findings 1
- Cardiac MRI in hemodynamically stable patients to confirm myocardial inflammation with characteristic delayed gadolinium enhancement patterns 1, 2
Corticosteroid Therapy: The Critical Decision Point
Intravenous corticosteroids are specifically indicated in three scenarios:
- COVID-19 myocarditis with concurrent pneumonia requiring supplemental oxygen 1
- Hemodynamic compromise or multisystem inflammatory syndrome in adults (MIS-A) 1, 2
- Fulminant myocarditis with biopsy-proven severe myocardial inflammatory infiltrates 1, 2
The combination of intravenous immunoglobulins and corticosteroids may be particularly effective in fulminant cases, though large randomized trials are still needed 4.
Heart Failure Management
Initiate guideline-directed medical therapy before discharge:
- ACE inhibitors or ARBs for neurohormonal blockade once hemodynamically stable 1, 2
- Low-dose aldosterone antagonists empirically in patients with mildly reduced LV function and stable hemodynamics 2
- Beta-blockers only if hemodynamically stable, particularly for supraventricular arrhythmias—avoid in compromised patients as they can precipitate cardiogenic shock 2
Continue titrating these medications in the outpatient setting 1, 2.
Anti-Inflammatory Therapy for Pericardial Involvement
If pericardial involvement is present:
- NSAIDs, colchicine, or prednisone are reasonable options 1
- Low-dose colchicine or prednisone may be added for persistent chest pain, with tapering based on symptoms 2
Critical caveat: NSAIDs should be absolutely avoided in isolated myocarditis without pericardial involvement due to increased inflammation and mortality risk in animal models 2.
Mechanical Circulatory Support
For patients developing cardiogenic shock despite optimal medical management, mechanical circulatory support may bridge patients to recovery 2. This requires transfer to centers with advanced capabilities 1.
Mandatory Activity Restriction
Complete exercise abstinence for 3-6 months is non-negotiable, as sustained aerobic exercise during acute viral myocarditis increases mortality and sudden death risk 1, 2. Competitive sports participation is prohibited during this entire period 2.
Return-to-play criteria after 3-6 months:
- Absence of cardiopulmonary symptoms 1
- Resolution of laboratory evidence of myocardial injury 1
- Normalization of LV systolic function 1
- Absence of spontaneous/inducible arrhythmias on ECG monitoring and exercise stress testing 1
Data from the Big Ten COVID-19 cardiac registry showed that inflammatory CMR findings resolved in 41% of athletes after a median of 8 weeks, though only 1 of 6 with clinical myocarditis had resolution after 10 weeks 1.
Arrhythmia Management
Manage arrhythmias supportively, as they typically resolve with resolution of acute inflammation 1, 2. For drug-refractory ventricular arrhythmias, endocardial and epicardial radiofrequency catheter ablation can be effective 2.
Immunosuppression: Generally Not Indicated
Do not use empiric immunosuppression for typical lymphocytic viral myocarditis, as it has not demonstrated benefit and increases infection risk 2. Immunosuppression is reserved for giant cell myocarditis, cardiac sarcoidosis, and eosinophilic myocarditis—not acute lymphocytic myocarditis in adults 2.
Follow-Up Surveillance Protocol
At 3-6 months after presentation, obtain:
For patients who had cardiogenic shock or hemodynamic instability, perform CMR before hospital discharge to confirm diagnosis and assess extent of dysfunction 2. Long-term monitoring is essential, as 21% of myocarditis patients develop dilated cardiomyopathy during follow-up 5.
Prognostic Considerations
COVID-19 patients with myocarditis have significantly higher in-hospital mortality (30.5% vs. 13.1% without myocarditis), along with increased cardiogenic shock, acute kidney injury requiring hemodialysis, sudden cardiac death, and need for mechanical ventilation and vasopressor support 6.