Myocarditis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.; Maliha Shakil, M.D. [2] Homa Najafi, M.D.[3]


Symptomatic treatment is the mainstay of therapy for patients with viral myocarditis. Supportive therapy includes diuretics and inotropes for left ventricular failure. ACE inhibitor therapy may aid in left ventricular remodeling. Among patients with fulminant myocarditis, placement of either an intra-aortic balloon pump or a left ventricular assist device may be necessary as bridge to recovery. Administration of antimicrobial therapy is recommended for bacterial myocarditis. Immunosuppressive therapy may be effective in the management of giant cell myocarditis, autoimmune myocarditis, and eosinophilic myocarditis. In patients with arrythmias, treatment should be initiated only if arrhythmias are symptomatic or sustained. Myocarditis patients presenting with conduction abnormalities, particularly Mobitz type II and complete heart block require temporary pacemaker usually during the acute phase.

Medical Therapy

Lymphocytic/Viral Myocarditis

Giant Cell Myocarditis

Eosinophilic Myocarditis

Autoimmune Myocarditis

Treatment of Heart Failure

  • For more information on heart failure treatment, click here.

Treatment of Arrhythmia

2006 ACC/AHA/ESC Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis[34]

Class I
1. Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis. (Level of Evidence: C)
2. Acute aortic regurgitation associated with VT should be treated surgically unless otherwise contraindicated.(Level of Evidence: C)
3. Acute endocarditis complicated by aortic or annular abscess and AV block should be treated surgically unless otherwise contraindicated. (Level of Evidence: C)
Class III
1.ICD implantation is not indicated during the acute phase of myocarditis. (Level of Evidence: C)
Class IIa
1. ICD implantation can be beneficial in patients with life-threatening ventricular arrhythmias who are not in the acute phase of myocarditis, as indicated in the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmic devices who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: C)[35]
2. Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis. (Level of Evidence: C)

2013 ESC Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis[36]

Class I
1. It is recommended that patients with a life-threatening presentation of sustained ventricular tachyarrhythmias in the context of clinically suspected myocarditis are referred to specialized centers with the ability to perform hemodynamic monitoring, cardiac catheterization and endomyocardial biopsy and to use mechanical cardio-pulmonary assist devices and specialized arrhythmia therapies. (Level of Evidence: C)[37][38][39][40]
2. Temporary pacemaker insertion is recommended in patients with bradycardia and/or heart block triggering VA during the acute phase of myocarditis/pancarditis.(Level of Evidence: C)[37][41]
Class IIa
1.Anti-arrhythmic therapy should be considered in patients with symptomatic non-sustained or sustained VT during the acute phase of myocarditis.(Level of Evidence: C)[37]
2. The implant of an ICD or pacemaker in patients with inflammatory heart diseases should be considered after resolution of the acute episode. (Level of Evidence: C)[37][42]
3. In patients with hemodynamically compromising sustained VT occurring after the resolution of acute episodes, an ICD implantation should be considered if the patient is expected to survive >1 year with good functional status. (Level of Evidence: C)
4. A wearable defibrillator should be considered for bridging until full recovery or ICD implantation in patients after inflammatory heart diseases with residual severe LV dysfunction and/or ventricular electrical instability. (Level of Evidence: C)[43][44]
Class IIb
1. ICD implantation may be considered earlier in patients with giant cell myocarditis or sarcoidosis who had hemodynamically compromising sustained VA or aborted cardiac arrest, due to adverse prognosis of these conditions, if survival >1 year with good functional status can be expected. (Level of Evidence: C)[45]
2. Demonstration of persistent myocardial inflammatory infiltrates by immunohistological evidence and/or abnormal localized fibrosis by CMR after acute myocarditis may be considered as an additional indicator of increased risk of SCD in inflammatory heart disease. (Level of Evidence: C)[46]


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