Treatment of Viral Myocarditis

Initial Risk Stratification and Hospitalization

The American College of Cardiology recommends that all patients with definite myocarditis require hospitalization, ideally at an advanced heart failure center, with the severity determining the level of care 2, 3
Patients with fulminant myocarditis require management at centers with expertise in advanced heart failure, mechanical circulatory support, and transplant capabilities 2, 3
Stable patients with chest pain as the only symptom, preserved LV function, and no ventricular arrhythmias can be managed in the ambulatory setting with close monitoring 4

The American College of Cardiology recommends guideline-directed medical therapy for heart failure, which should be initiated before discharge and titrated in the outpatient setting 2, 3
Low-dose aldosterone system inhibitors may be used empirically in patients with mildly reduced LV systolic function and stable hemodynamics 3
Beta-blockers may be helpful in patients with supraventricular arrhythmias if hemodynamically stable, but can precipitate cardiogenic shock in patients with greater cardiac compromise 3

For patients with associated pericardial involvement, nonsteroidal anti-inflammatory drugs may be used to alleviate chest pain and inflammation, but should generally be avoided in isolated myocarditis due to risk of increased inflammation and mortality 1, 2, 3
Low-dose colchicine or prednisone may be added for persistent chest pain, with tapering based on symptoms and clinical findings 2, 3

The American College of Cardiology recommends immunosuppression for giant cell myocarditis, cardiac sarcoidosis, and eosinophilic myocarditis, but not for acute lymphocytic myocarditis in adults 1
Empiric corticosteroids may be considered in fulminant myocarditis with biopsy evidence of severe myocardial inflammatory infiltrates, or in patients with hemodynamic compromise or MIS-A 2, 3

Competitive sport participation and strenuous physical activity must be avoided for 3-6 months after diagnosis, as sustained aerobic exercise during acute viral myocarditis can lead to increased mortality and sudden death 1, 3

For patients developing cardiogenic shock despite optimal medical management, mechanical circulatory support may be required, with some patients able to be bridged to recovery 1

Follow-up surveillance testing is essential in all patients with myocarditis, and should include ECG, echocardiogram, ambulatory rhythm monitor, and CMR at 3-6 months after presentation 2, 3, 4
CMR should be performed before hospital discharge in patients who had cardiogenic shock or hemodynamic instability to confirm diagnosis and assess extent of dysfunction 2, 3

Acute arrhythmia management is supportive, as arrhythmias often resolve with resolution of acute inflammation, but endocardial and epicardial radiofrequency catheter ablation can be effective for drug-refractory ventricular arrhythmias 1

NSAIDs should not be used routinely in isolated myocarditis without pericardial involvement due to increased inflammation risk 1
Beta-blockers should not be initiated in hemodynamically compromised patients as they can precipitate cardiogenic shock 3
Empiric immunosuppression should not be used for typical lymphocytic viral myocarditis, as it has not demonstrated benefit and increases infection risk 1
Early return to exercise should not be allowed before the 3-6 month restriction period and proper reassessment 1, 3