Fast Five Quiz: Myocarditis

Yasmine S. Ali, MD


December 13, 2021

Because many cases of myocarditis are not clinically obvious, a high degree of suspicion is required to identify acute myocarditis. Fortunately, most patients have mild symptoms consistent with viral syndromes, and they recover with simple supportive care on an outpatient basis, including with slow rehabilitation and the implementation of evidence-based medical therapy. Repeat assessment with echocardiography may be helpful to determine the persistence of cardiac dysfunction.

Nonsteroidal anti-inflammatory agents should be avoided in the acute phase of myocarditis, as their use may impede myocardial healing and actually exacerbate the inflammatory process and increase the risk for mortality. Treatment of myocarditis includes supportive therapy for symptoms of acute heart failure with use of diuretics, nitroglycerin/nitroprusside, and angiotensin-converting enzyme (ACE) inhibitors. Inotropic drugs (eg, dobutamine, milrinone) may be necessary for severe decompensation, although they are highly arrhythmogenic. Long-term treatment follows the same medical regimen, including ACE inhibitors, beta-blockers, and aldosterone receptor antagonists. In some instances, however, some of these drugs cannot be implemented initially because of hemodynamic instability.

In those with fulminant myocarditis and sinus tachycardia, avoid the use of rate-control agents (in particular, those with negative inotropic properties, including metoprolol, diltiazem, and verapamil). Also, avoid the use of nonsteroidal anti-inflammatory agents (NSAIDs) to avoid increasing sodium retention, myocardial harm, and exacerbation of renal hypoperfusion.

Statins may be beneficial in COVID-19 and have been shown to attenuate myocarditis, but additional studies are needed.

Immunosuppression has not been demonstrated to change the natural history of infectious myocarditis. The Heart Failure Society of America recommends against routine use of immunosuppressive therapy.

Read more on the treatment of myocarditis.

This Fast Five Quiz was excerpted and adapted from the Medscape Drugs & Diseases article Myocarditis.

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