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Subsections
Myocarditis: Treatment

Cardiovascular

Myocarditis: Treatment

Initial/Prep/Goals

  1. Primarily focuses on supportive care, monitoring, and management of heart failure
    • Treatment is tailored by disease severity
    • Maintain ABC and manage cardiac emergencies according to PALS
    • Stabilize the patient hemodynamically
    • Manage heart failure and its complication
    • Manage arrhythmia and its complication
    • For patients with pulmonary edema positive pressure ventilation may be required
  2. If the patient presents with cardiogenic shock, decrease metabolic demand by
    • Sedation
    • Intubation and
    • Mechanical ventilation
  3. Severe and unresponsive cases may be managed by
    • Extracorporeal membrane oxygenation (ECMO) or
    • A ventricular assist device

Medical/Pharmaceutical

  1. If the patient presents with congestive heart failure give
  2. If the patient develops chronic heart failure give
  3. Combination of ACE-I and Beta-blockade + selective use of aldosterone antagonists in symptomatic heart failure
  4. Cardiogenic shock/Refractory to medical treatment
  5. Immunosuppressive therapy
    • Benefit not established 11
  6. IVIG (Intravenous immunoglobulins) 14
    • Doesn't impact survival
  7. Antiarrhythmics should be given accordingly in consultation with a pediatric cardiologist

Surgical/Procedural

  1. Heart transplantation remains the final therapeutic option for children with myocarditis and intractable severe heart failure 11
  2. ECMO
  3. Pacing
  4. Ventricular assist devices

Complications

  1. Heart failure
  2. Dilated cardiomyopathy
  3. Arrhythmia
  4. Need for cardiac transplantation
  5. Death

Prevention

  1. Prevention of etiological agents

Disposition

  1. Admit all
  2. Consult
    • Pediatric cardiologists
  3. Discharge/Follow-up instructions
    • Long-term follow up should be guided by a pediatric cardiologist
    • Adequate rest
    • Avoid strenuous exercise

Related Topics

References

  1. Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc. 2009; 84(11):1001–1009.
  2. Dancea AB. Myocarditis in infants and children: A review for the paediatrician. Paediatr Child Health. 2001;6(8):543-545.
  3. Kühl U, Pauschinger M, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. 2005;112(13):1965-1970.
  4. Fong IW. New Perspectives of infections in cardiovascular disease. Curr Cardiol Rev. 2009;5(2):87-104.
  5. Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation. 2006;113:876-890.
  6. Cioc AM, Nuovo GJ. Histologic and in situ viral findings in the myocardium in cases of sudden, unexpected death. Mod Pathol. 2002;15(9):914-922.
  7. Råsten-Almqvist P, Eksborg S, Rajs J. Myocarditis and sudden infant death syndrome. APMIS. 2002;110(6):469-80.
  8. Kliegman RM, Stanton BF, et al. Myocarditis. In: Nelson's Textbook of Pediatrics 19th ed. Philadelphia, PA: Elsevier-Saunders; 2011;433
  9. Ghelani SJ, Spaeder MC, et al. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes. 2012;5(5):622-627.
  10. Cooper LT, Baughman KL, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. Eur Heart J. 2007;28(24):3076-3093.
  11. Freedman SB, Haladyn JK, et al. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007;120(6):1278-1285.
  12. Durani Y, Egan M, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009;27:942–947.
  13. Vashist S, Singh GK. Acute myocarditis in children: current concepts and management. Curr Treat Options Cardiovasc Med. 2009;11(5):383-391.
  14. Klugman D, Berger JT, et al. Pediatric patients hospitalized with myocarditis: a multi-institutional analysis. Pediatr Cardiol. 2010;31(2):222-228.
  15. Mavrogeni S, Bratis K, et al. Evaluation of myocarditis in a pediatric population using cardiovascular magnetic resonance and endomyocardial biopsy. Int J Cardiol. 2012;18;160(3):192-5.
  16. Heinz-Peter Schultheiss,Uwe Kühl et al. The management of myocarditis. Eur Heart J. 2011;32(21):2616-2625.
  17. Shu-Ling C, Bautista D, et al. Diagnostic evaluation of pediatric myocarditis in the emergency department: a 10-year case series in the asian population. Pediatr Emerg Care. 2013;29(3):346-351.
  18. Teele SA, Allan CK, et al. Management and outcomes in pediatric patients presenting with acute fulminant myocarditis. J Pediatr. 2011;158(4):638-643.
  19. Canter CE, Simpson KE. Diagnosis and treatment of myocarditis in children in the current era. Circulation. Jan 7, 2014 Jan 7;129(1):115-128
  20. Frobel AK, Hulpke-Wette M, Schmidt KG, Läer S. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev. 2009; (1):CD007037
  21. Alabed S, Sabouni A, Al Dakhoul S, Bdaiwi Y, Frobel-Mercier AK. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev. 2016 Jan 28;(1):CD007037.

Contributor(s)

  1. Sindhwani, Maughan K., MD

Updated/Reviewed: October 2019