Myocarditis: What’s new for 2025

Summary

In this interview, Dr. Leslie Cooper, a leading expert on myocarditis, discusses the latest updates on the condition in 2025. He covers key advancements from the 2024 American College of Cardiology's Expert Consensus Decision Pathway (EDCP), highlighting new diagnostic stages, genetic testing, and the management of patients with myocarditis. Dr. Cooper emphasizes the importance of timely diagnosis through cardiac MRI and PET scans, while also offering insights into treatment protocols, including colchicine and NSAIDs. He also explains the follow-up process, recommending a three-month window before patients return to physical activity. The interview provides invaluable guidance for clinicians managing myocarditis cases.

Takeaways

• 😀 Myocarditis is a complex condition that can mimic other heart diseases like myocardial infarction, pericarditis, and heart failure, and should be considered when these conditions are excluded.
• 😀 Initial diagnostic tests for myocarditis include troponin, NT-proBNP, BNP, echocardiogram, and EKG, but cardiac MRI and PET scans are key tests for more definitive diagnosis.
• 😀 Echo findings like basal septal aneurysm or generalized hypokinesis can indicate myocarditis, prompting further investigation with MRI or PET scans.
• 😀 The 2024 Expert Consensus Decision Pathway (EDCP) defines four stages of myocarditis: Stage A (at risk), Stage B (asymptomatic but with heart disease), Stage C (symptomatic), and Stage D (end-stage requiring advanced support).
• 😀 Genetic testing for cardiomyopathy genes is recommended for patients with new onset or confirmed myocarditis, especially for those with severe disease, recurrent episodes, or a family history of myocarditis.
• 😀 Myocarditis patients with severe disease or ventricular arrhythmias may have a 20% or higher chance of a pathogenic gene mutation, with even higher rates in children.
• 😀 For follow-up after myocarditis, an echocardiogram should be done within 2-4 weeks to assess LV function, as some patients may deteriorate despite initial improvement.
• 😀 Patients with myocarditis can gradually return to low-level physical activity after about 3 months, but should avoid high-intensity sports like NCAA-level athletics during the recovery period.
• 😀 Colchicine and low-dose NSAIDs may be used to treat myocarditis, with colchicine shown to reduce recurrent myopericarditis by 50% over two years in some cases.
• 😀 Heart biopsy is reserved for patients with severe or complicated myocarditis, such as those with unexplained cardiogenic shock or persistent ventricular arrhythmias, to help diagnose conditions like giant cell myocarditis.

Q & A

What is myocarditis and why is it important to understand in 2025?

Myocarditis is an inflammation of the heart muscle that can lead to severe complications, including heart failure, arrhythmias, and even death. In 2025, new insights and research, particularly the American College of Cardiology Expert Consensus Decision Pathway (EDCP), have highlighted important developments in diagnosing and managing the condition.

How can myocarditis present in clinical settings?

Myocarditis can present in several ways, including chest pain similar to a heart attack, symptoms of heart failure like shortness of breath, fluid congestion, and arrhythmias such as ventricular tachycardia or heart block. It's often a challenge to differentiate it from ischemic heart disease.

What initial tests are typically used to diagnose myocarditis?

Initial tests include non-specific markers like troponin levels, NT-proBNP or BNP, an echocardiogram, and an EKG. These tests help identify myocardial injury and assess heart function, though further tests like cardiac MRI or PET scans are required for a definitive diagnosis.

How do echocardiogram findings help in diagnosing myocarditis?

Echocardiograms may reveal signs like basal septal aneurysms or generalized hypokinesis, which can indicate myocarditis, especially when the pattern doesn’t match typical ischemic heart disease. These findings should prompt further investigation with MRI or PET scans for a more accurate diagnosis.

What are the four stages of myocarditis as defined in the 2024 EDCP guidelines?

The four stages are: Stage A (at-risk individuals with higher risk due to factors like immune checkpoint inhibitors or specific genetic mutations), Stage B (asymptomatic individuals with evidence of structural heart disease), Stage C (patients with symptoms such as chest pain or shortness of breath), and Stage D (end-stage cardiomyopathy requiring advanced support like a ventricular assist device).

When should genetic testing be considered for patients with myocarditis?

Genetic testing is recommended for patients with new onset or confirmed myocarditis, particularly those with severe disease like reduced ejection fraction or sustained arrhythmias. It is especially crucial for those with a family history of myocarditis or recurrent episodes of the condition.

What role does genetics play in myocarditis?

Recent studies show that about 20% of patients with severe myocarditis carry pathogenic mutations related to cardiomyopathy genes. Genetic testing can help identify underlying genetic causes, particularly in patients with severe disease or a family history of myocarditis.

What is the recommended approach to patient activity after a diagnosis of myocarditis?

After a diagnosis of myocarditis, the EDCP recommends a three-month window of low-level activity. Patients can resume activities of daily living and some recreational sports but should avoid competitive sports like NCAA-level athletics due to the risk of worsening heart disease or arrhythmias.

What is the treatment approach for myocarditis and when should colchicine be considered?

For typical viral myocarditis, colchicine and low-dose NSAIDs are often used, especially for reducing recurrence. Colchicine has been shown to reduce the rate of recurrent myopericarditis by approximately 50%. However, NSAIDs should be avoided in patients with reduced ejection fraction due to the risk of worsening heart failure.

How should patients with severe myocarditis, such as those with cardiogenic shock or ventricular arrhythmias, be managed?

Patients with severe myocarditis, such as those with cardiogenic shock or sustained ventricular arrhythmias, may require heart biopsy to diagnose conditions like giant cell myocarditis or other autoimmune causes. These patients often need specialized care at tertiary centers with expertise in myocarditis management.