10th May 2025

Medical Management

In general, treatment is supportive and symptomatic. Patients are advised to avoid strenuous activity for at least six months, often following outpatient review with a Cardiologist and repeat echocardiogram. Treating the offending agent or infection is vital, and for those in which the agent can be removed entirely, e.g. alcohol, the recovery is very good. Non-steroidal anti-inflammatory drugs (NSAIDs), which are a mainstay of therapy in pericarditis, are not recommended in myocarditis due to their potential risk of worsening heart failure. 

For patients in which myocarditis has led to heart failure with reduced ejection fraction, they are treated as per heart failure with the four pillars of prognostic heart failure medications:

• Angiotensin‐converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) or an angiotensin receptor-neprilysin inhibitor (ARNi)
• β‐blocker
• Mineralocorticoid receptor antagonist (MRA)
• Sodium‐glucose cotransporter 2 inhibitor (SGLT2i).

Additionally, any symptomatic arrhythmias should be controlled. There is poor evidence of immunosuppressive therapy in patients with myocarditis, apart from those in specific cases (i.e. autoimmune diseases, especially sarcoidosis, giant cell myocarditis or autoimmune rheumatic diseases) so the use of steroids can be considered but the benefit is unproven outside of these cases. Multispecialty input may be required for patients in which the aetiology is complex, such as infectious diseases, rheumatology, immunology and respiratory medicine.