Fulminant myocarditis identification and initial management: AHA scientific statement

Fulminant myocarditis (FM) is an uncommon syndrome of sudden and severe diffuse myocardial inflammation, often with cardiogenic shock, ventricular arrhythmia, or multisystem death due to exhaustion. Historically, FM has almost always been diagnosed at autopsy. By definition, all patients with FM require inotropes or mechanical circulatory support to maintain organ perfusion until transplantation or recovery. Special FM types are effective for immunomodulatory therapy on the basis of guideline-recommended therapy.

This scientific statement highlights the resources needed to manage FM, including extracorporeal life support, percutaneous and continuous ventricular assist devices, transplant capabilities, and Specialist in severe heart failure, cardiothoracic surgery, cardiac pathology, immunology and infectious diseases.

Potential clues and pitfalls of FM assessment and early processing:

1. Diagnosis

(1) Young patients, obvious cardiovascular problems, ACS or new-onset acute heart failure are common and should be considered myocarditis.

(2) Young patients, no typical cardiovascular risk factors, recent symptoms and signs of upper respiratory tract viral infection or enterovirus infection, manifested as cardiac Vascular system symptoms.

(3) Any patient with shock, electrical instability, or rapidly progressive conduction abnormalities (such as QRS interval widening or PR prolongation).

(4) Identify typical symptoms and signs of right heart failure, such as right chest pain, abnormal liver function, jaundice, jugular vein filling, peripheral edema , Hepatomegaly with liver pulsation. It needs to be differentiated from primary hepatobiliary disease.

2. Notes

(1) Early Identify circulatory instability, such as low pulse compression, sinus tachycardia, cold or patterned extremities, or elevated lactate.

(2) The patient may show weakness after severe infection. Severe myocarditis can also be present, although infection and sepsis are more commonly diagnosed.

(3) The identification of sepsis from early cardiogenic shock secondary to myocarditis is challenging.

3. Initial processing

(1) Avoid Treat sinus tachycardia with rate-controlling drugs (especially negative inotropic drugs such as metoprolol, diltiazem, or verapamil).

(2) In patients with systolic dysfunction, cardiac output largely depends on the increase in heart rate.

(3) Partial eosinophilic myocarditis, usually manifested as FM with peripheral eosinophilia (65% of patients), rash or Hypersensitivity myocarditis should be considered when liver enzymes are elevated.

(4) Patients usually have fever and are at high risk of death, transplantation or VAD implantation at 120 days.

(5) EMB is usually required to confirm the diagnosis.

(6) Commonly used antibiotics include beta-lactams and minocycline; certain central nervous system drugs such as clozapine and carbamazepine .

(7) Avoid NSAIDs because they increase sodium retention, damage the myocardium and exacerbate renal hypoperfusion.

2 examples of cardiac MRI are shown below,

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Acute myocarditis An example of CMR in the chronic and chronic phases is shown below,

EMB indications are shown below,

The initial treatment process for patients with cardiogenic shock is shown in the figure below,

Suspected early FM The initial examination items for hemodynamically stable patients in the emergency department are shown in the table below.

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FM initial processing considerations are shown in the table below,

The etiology of lymphocytic myocarditis is shown below,

Some studies on the treatment of lymphocytic myocarditis are available in Below table,

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The pathological example of giant cell myocarditis is shown in the figure below,

and necrophilic Drugs related to granulocytic myocarditis are shown in the table below,

The pathological example of necrotizing eosinophilic myocarditis is shown below,

The main types of myocarditis that cause FM are shown in the table below,

Circulation. 2020;141:e69–e92.