Myocarditis Treatment Guidelines

Immediate Management and Hospitalization

All patients with definite myocarditis should be hospitalized, ideally at an advanced heart failure center, according to the American College of Cardiology 1
Patients with ventricular arrhythmias or heart block require immediate hospitalization and intensive monitoring, as recommended by the American Heart Association 2, 1, 3

A 12-lead ECG should be performed to assess for conduction abnormalities, ST-segment changes, and QRS widening, as recommended by the American College of Cardiology 1, 3
Cardiac biomarkers, including troponin and creatine kinase levels, should be measured, as recommended by the National Comprehensive Cancer Network 5, 1
A transthoracic echocardiogram should be performed to evaluate ventricular function and wall motion abnormalities, as recommended by the American College of Cardiology 1, 3
Cardiac MRI should be considered in hemodynamically stable patients to confirm diagnosis and assess extent of inflammation, as recommended by the American College of Cardiology 1, 3

Guideline-directed medical therapy for heart failure should be initiated before discharge and titrated in the outpatient setting, as recommended by the American College of Cardiology 1
ACE inhibitors or ARBs should be used for neurohormonal blockade, as recommended by the American Heart Association 4
Beta-blockers should be used for patients with supraventricular arrhythmias, if hemodynamically stable, as recommended by the American College of Cardiology 1, 4

Patients with fulminant myocarditis should be managed at centers with expertise in advanced heart failure, as recommended by the American College of Cardiology 1
Mechanical circulatory support may be required, including percutaneous cardiopulmonary support or intra-aortic balloon pump, as recommended by the American Heart Association 1, 4
The short-term mortality for fulminant myocarditis is approximately 28% at 60 days for those requiring mechanical support, as reported by the American College of Cardiology 4

Immunosuppression is generally not indicated for acute lymphocytic myocarditis in adults, as recommended by the American College of Cardiology 1
Immunosuppressive therapy should be considered in specific circumstances, such as giant cell myocarditis or cardiac sarcoidosis, as recommended by the American College of Cardiology 1
High-dose methylprednisolone 1 mg/kg IV should be used for at least several days until improvement to grade ≤1, as recommended by the Journal for ImmunoTherapy of Cancer 2

For patients developing myocarditis on immunotherapy, the immune checkpoint inhibitor should be permanently discontinued for grade 3-4 cardiac toxicity, as recommended by the National Comprehensive Cancer Network 5, 2
High-dose corticosteroids should be initiated immediately (methylprednisolone 1 mg/kg IV), as recommended by the National Comprehensive Cancer Network 5, 2
Mortality remains high at 23% despite rapid treatment, with conduction abnormalities being the primary mode of death, as reported by the National Comprehensive Cancer Network 5

Follow-up surveillance testing should be performed 3-6 months after presentation to assess recovery of cardiac function and inflammation, as recommended by the American College of Cardiology 1
Repeat echocardiography or cardiac MRI should be performed to assess ventricular function, as recommended by the American College of Cardiology 1
Reassessment of cardiac biomarkers should be performed, as recommended by the American College of Cardiology 1
Dilated cardiomyopathy develops in 21% of patients during long-term follow-up, as reported by the American College of Cardiology 4
Cardiac transplantation survival rates for myocarditis are similar to other causes of cardiac failure, as reported by the American College of Cardiology 1