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Management of patients with heart failure and suspected myocarditis

Clinical history, signs and symptoms, ECG, laboratory, echocardiography, CMR imaging, coronary CT/CAGa

Treatment of CAD if present

and indicated Suspected auto-immunity,

infectious, toxic

HF treatment

Clinical stabilization EMB if any doubt

about diagnosis

Maintain HF treatment Consider immunosuppressive

therapy or anti-infection

Y N

Consider MCS

Figure 20 Management of patients with heart failure and acute myocarditis. ACS= acute coronary syndrome; CAD= coronary artery disease; CAG= coronary artery angiogram; CMR= cardiac magnetic resonance; CT= computed tomography; ECG =electrocardiogram; EMB= endomyocardial biopsy; HF= heart failure; MCS= mechanical circulatory support. aTo exclude CAD/ACS.

Table 32 Endomyocardial biopsy in patients with suspected myocarditis

Indication (see also Section 4.3). Progressive or persistent severe cardiac dysfunction and/or life-threatening ventricular arrhythmias and/or Mobitz type 2 second-degree or higher AV block with lack of short-term (<1-2 weeks) expected response to usual medical treatment. The aim is to identify aetiology and to indicate specific treatment (e.g. giant cell myocarditis, eosinophilic myocarditis, cardiac sarcoidosis, systemic inflammatory disorders).97,98,917,918,958 Number and sites of the samples A minimum of 5 but possibly at least 7 samples, 3 for pathology, 2 for infections (DNA, PCR) and 2 for RNA viruses/viral replication. Left and/or right ventricle. CMR or PET guided sampling may be considered.919 Aetiology Quantitative PCR viral genome analysis for common cardiotrophic viruses (parvovirus B19, HHV4, HHV6, enteroviruses, adenovirus and coxsackievirus) by rtPCR. Viral mRNA for active viral replication may be assessed although it has low sensitivity. On indication, search for CMV, HIV, Borrelia, Coxiella burnetii (Q-fever) and SARS-CoV-2. Diagnosis of inflammation Immunohistochemistry with staining for anti-CD3-, CD4-, CD8- or CD45 antibodies for lymphocytes and anti-CD68 antibodies for macrophages and anti- HLA-DR antibodies.907,917,918,959 Therapeutic implications Immunosuppressive therapy may be indicated based on the results of EMB as in giant cell myocarditis or eosinophilic myocarditis and, possibly, also in sarcoidosis, vasculitis or selected patients with increased cardiac inflammation of unknown origin based upon multidisciplinary counselling.98,917919,954 Antibiotics: Borrelia (Lyme disease). Antiviral therapy: HIV, CMV, HHV6 pending on load and viral replication (mRNA).

CMR = cardiac magnetic resonance; CMV = cytomegalovirus; DNA = deoxyribonucleic acid; EMB = endomyocardial biopsy; HHV = human herpes virus; HIV = human immunodeficiency virus; HLA-DR = human leucocyte antigen-DR isotype; mRNA = messenger ribonucleic acid; PCR = polymerase chain reaction; PET = positron emission tomography; RNA = ribonucleic acid; rtPCR = reverse transcriptase polymerase chain reaction; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026