Corticosteroids in Myocarditis
Primary Recommendation
- The European Society of Cardiology gives a Class III (harm) recommendation against corticosteroids in viral pericarditis/myocarditis due to risk of viral reactivation 1
When to AVOID Corticosteroids
- NSAIDs and corticosteroids may actually increase inflammation and mortality in isolated myocarditis without pericardial involvement 2, 3, 1
- Do not use corticosteroids in typical viral myocarditis - they do not reduce mortality (RR 0.93, 95% CI 0.70-1.24) and can reactivate viral infections, perpetuating inflammation rather than resolving it 1
When to CONSIDER Corticosteroids
- Use corticosteroids if patient has both myocarditis AND COVID-19 pneumonia requiring supplemental oxygen 5
- Intravenous corticosteroids may be considered in suspected/confirmed COVID-19 myocarditis with hemodynamic instability or multisystem inflammatory syndrome in adults (MIS-A) 5
- Emergent high-dose corticosteroids (1 mg/kg methylprednisolone IV) should be initiated immediately in suspected or confirmed cases of immune checkpoint inhibitor myocarditis 1, 6
- Giant cell myocarditis: Immunosuppression indicated 1
- Cardiac sarcoidosis: Immunosuppression indicated 1
- Eosinophilic myocarditis: Corticosteroids are standard treatment 1
Recommended Treatment Approach Instead
- Guideline-directed medical therapy for heart failure: ACE inhibitors/ARBs, beta-blockers (if hemodynamically stable), aldosterone antagonists 1
- Activity restriction for 3-6 months - sustained aerobic exercise during acute viral myocarditis increases mortality and sudden death risk 3, 1
- Mechanical circulatory support if cardiogenic shock develops despite optimal medical management 1
Diagnostic Workup Required
- Cardiac MRI recommended in hemodynamically stable patients with suspected myocarditis for definitive diagnosis 5, 3
- Consider endomyocardial biopsy if diagnosis unclear or to guide immunosuppression decisions 3