This handout is for acute hf — immune checkpoint inhibitor (ici) cardiotoxicity / fulminant myocarditis. Your care team identified this based on: patient on active pd-1/pd-l1/ctla-4 inhibitor (nivolumab, pembrolizumab, ipilimumab, atezolizumab, durvalumab, avelumab, cemiplimab) presenting with new dyspnea, chest pain, palpitations, or syncope — ici myocarditis until proven otherwise.
Other reasons your team may use this plan: any troponin elevation in an ici patient — stat cardiology consult; treat empirically with high-dose methylprednisolone while workup proceeds (mahmood jacc 2018 pmid 29420041 — delay = death); new high-grade av block, ventricular arrhythmia, or qrs widening in ici patient (4-6 wk post-initiation peak) — fulminant ici myocarditis pattern; ici patient with myocarditis features + concomitant myositis (ck elevation), myasthenia gravis, or hepatitis — combined irae pattern with worse prognosis.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| methylprednisolone | 1 g IV daily ×3-5 d then prednisone 1 mg/kg PO taper | IV | daily | Mahmood JACC 2018 PMID 29420041 — high-dose steroid is FIRST-LINE; treat empirically; delay = death; ESMO + NCCN + AHA 2022 cardio-onc |
| abatacept | 10 mg/kg IV q2 weeks (5 doses) | IV | q2 weeks | Salem RIVAL PMID 39432268 — abatacept (CTLA-4 Ig) reduces 90-day mortality in steroid-refractory ICI myocarditis; preferred salvage over infliximab in HF |
| mycophenolate mofetil | 1 g PO BID | PO | BID | Steroid-sparing immunosuppressant in refractory ICI myocarditis; ESMO + NCCN guidelines support |
| IVIG (immunoglobulin G) | 2 g/kg IV divided over 2-5 days | IV | as scheduled | Refractory ICI myocarditis salvage; useful when concomitant myasthenia gravis or other irAE present |
| infliximab | CONTRAINDICATED for cardiac ICI myocarditis | IV | do_not_use | TNF-α inhibitor worsens cardiac HF; CONTRAINDICATED for ICI myocarditis with HF or LVEF reduction; abatacept preferred salvage; only consider for non-cardiac irAE if no HF |
| furosemide | 40-80 mg IV bolus then 5-10 mg/h infusion | IV | as scheduled | Standard ADHF diuresis; DOSE PMID 21366472 |
| norepinephrine | 0.05-0.5 µg/kg/min titrate to MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — first vasopressor in cardiogenic shock |
| carvedilol | 3.125 mg PO BID titrate | PO | BID | GDMT once stable; CAPRICORN PMID 11356436; ESC cardio-onc 2022 PMID 36017575 |
| sacubitril-valsartan | 24/26 mg PO BID titrate | PO | BID | PIONEER-HF PMID 30403955; ESC cardio-onc 2022 Class IIa |
| spironolactone | 12.5-25 mg PO daily | PO | daily | RALES PMID 10471456; ESC cardio-onc 2022 Class I |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356; ESC cardio-onc 2022 Class IIa |
Plan: ICI myocarditis storm protocol — high-dose steroid first-line, abatacept salvage, infliximab CONTRAINDICATED for cardiac, plus standard ADHF backbone
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardio-oncology clinic at 2 weeks, 6 weeks, 3 months, 6 months, 12 months; serial troponin + echo + MRI for surveillance; permanent ICI hold (rechallenge contraindicated per Power PMID 33779739); shared decision on alternative non-ICI cancer therapy with oncology; ICD evaluation if persistent heart pumping strength (LVEF) <35% on full the four foundational heart-failure medications; long-term steroid taper monitoring
Guideline: ESC cardio-oncology 2022 + Mahmood ICI myocarditis JACC 2018 + AHA cardio-oncology 2022 + Salem RIVAL abatacept refractory ICI myocarditis