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Fulminant Myocarditis – Recognition and Management from the AHA

February 12, 2020

Written by Clay Smith

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This is what you need to know to recognize and manage fulminant myocarditis (FM) in the ED.

Why does this matter?
FM is: “a sudden and severe inflammation of the myocardium resulting in myocyte necrosis, edema, and cardiogenic shock.” It is a masquerader. Here are the pearls and pitfalls to spot it and treat it.

My achy breaky heart
This is an AHA Scientific Statement on FM. Our focus is on ED management.

  • Presentation – Dyspnea, chest pain, and arrhythmia, such as atrial or ventricular fibrillation are common presentations. Patients may present in shock and may have acute infectious symptoms; shock may appear septic but is likely cardiogenic. Consider FM in young patients with ACS-like or acute CHF presentation, especially when lacking typical risk factors. Ask about preceding illness. Right heart failure may cause hepatic congestion masquerading as a “liver disease” picture. Consider hypersensitivity FM from drugs like beta-lactams or carbamazepine.

  • ECG – It may show low voltage, ST-elevation mimicking acute injury, pericarditis-like changes with diffuse ST-elevation +/- PR depression. Ectopy, ventricular arrhythmias, and conduction blocks (long PR, Mobitz type II) are also common. Look for early changes of widened QRS or PR prolongation.

  • Labs – Troponin is usually markedly elevated as is BNP. If eosinophilia, ask about new medications and consider necrotizing eosinophilic myocarditis.

  • Imaging – Echocardiogram is the imaging study of choice. MRI or nuclear studies may be done later.

  • Treatment – If FM is suspected, don’t give too much fluid. Use norepinephrine as the vasopressor of choice; avoid dopamine. Avoid rate controllers with negative inotropy – they need tachycardia to maintain cardiac output. Avoid NSAIDs – they make sodium retention worse. Involve cardiology early to rule out coronary artery disease and to deploy invasive hemodynamic support if needed.

  • Disposition – If transferring with heart failure symptoms, it should be to a transplant center that can also do ECMO.

  • Prognosis – Ironically, those with the worst initial hemodynamic collapse often have the best chance of full recovery – if they survive the initial insult.

Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association. Circulation. 2020 Jan 6:CIR0000000000000745. doi: 10.1161/CIR.0000000000000745. [Epub ahead of print]

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