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Treatment of Myocarditis

Conventional treatment of patients with myocarditis begins with guideline-directed management of arrhythmias and heart failure. When specific causes can be identified, targeted therapy is indicated, according to a review article. Myocarditis can be reversible, and the main goals of treatment are “biventricular unloading, adequate systemic and coronary perfusion, and venous decongestion, in an effort to prevent multiorgan dysfunction and provide a bridge to recovery, transplantation, or use of a durable assist device.”

Medications used for heart failure depend on whether patients are hemodynamically stable or unstable. “Patients with hemodynamically stable heart failure should be treated with diuretic agents, angiotensin-converting–enzyme inhibitors, or angiotensin-receptor blockade and beta-adrenergic blockade,” explain the authors. “Additional treatment with aldosterone antagonists should be considered in patients with persistent heart failure despite adequate management. Whether early initiation of treatment should also be offered to patients with preserved [left ventricular ejection fraction] in order to reduce inflammation, remodeling, and scarring remains uncertain.”

Inotropic agents are used in managing patients with hemodynamically unstable heart failure. Treatment should be in an ICU with respiratory and mechanical cardiopulmonary support facilities, and clinicians should consider referral to a tertiary care center. Mechanical circulatory support with ventricular assist devices or extracorporeal membrane oxygenation, or ECMO, may be needed to manage cardiogenic shock with severe ventricular dysfunction refractory to medical therapy.

Arrhythmias and conduction disturbances are managed according to current guidelines, with no specific recommendations for myocarditis. Condition-specific therapy of myocarditis is used when a specific cause can be identified, such as in eosinophilic myocarditis, giant-cell myocarditis, and cardiac sarcoidosis. Glucocorticoids, immunosuppressive agents, and antiviral therapy have been studied in clinical trials with varying results.

Source: New England Journal of Medicine