Patient handout

Acute HF — eosinophilic myocarditis decompensation (non-shock)

PRODUCTION

1. Your condition

This handout is for acute hf — eosinophilic myocarditis decompensation (non-shock). Your care team identified this based on: peripheral absolute eosinophil count >1500/µl (often >5000) + new adhf symptoms (dyspnea, orthopnea, edema) + lv dysfunction on echo + elevated troponin → eosinophilic myocarditis until proven otherwise.

Other reasons your team may use this plan: recent drug exposure (sulfa, penicillin, minocycline, clozapine, olanzapine, phenytoin, carbamazepine, lamotrigine, allopurinol) + dress features (fever, rash, lymphadenopathy, eosinophilia, multiorgan) + new adhf — drug-induced eosinophilic myocarditis pathway; asthma + sinusitis + peripheral eosinophilia + anca + new adhf → egpa (churg-strauss) cardiac involvement; cardiac is leading cause of death in egpa; cardiac mri with subendocardial lge pattern (classic loeffler endocarditis distribution) + edema on t2 mapping + peripheral eosinophilia → em diagnosis with high specificity.

2. Your medications

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 (pulse) then prednisone 1 mg/kg/d PO taper over 6-12 mo	IV	daily × 3-5 d then PO taper	CORNERSTONE — pulse methylprednisolone for active EM; dramatic response in 24-72 h in most cases; eosinophil count drops rapidly (supports diagnosis); prednisone taper guided by eosinophil count + clinical status; ESC 2013 (PMID 23824828) + AHA 2020 (PMID 32200645)
prednisone	1 mg/kg/d PO daily then taper by 10 mg q2wk to 20 mg then by 5 mg/mo to 5 mg then off; total 6-12 mo	PO	daily	Maintenance immunosuppression after pulse; titrated by eosinophil count + clinical response; prophylaxis against PCP (TMP-SMX) + steroid-induced osteoporosis (calcium + vit D ± bisphosphonate) standard
ivermectin	200 mcg/kg PO × 1-2 doses (uncomplicated strongyloides) or 200 mcg/kg/d × 2 d (disseminated)	PO	single dose or 2 d	MANDATORY before steroids if any strongyloides risk — steroids precipitate hyperinfection syndrome (mortality >70%); empiric coverage acceptable if serology pending
albendazole	400 mg PO BID × 14 d (toxocara, strongyloides alternative); 400 mg PO daily × 8-30 d (hydatid)	PO	BID × 14 d	Broad antihelminthic for parasitic EM; strongyloides alternative when ivermectin contraindicated
praziquantel	40 mg/kg PO total in 2 divided doses (schistosomiasis)	PO	split dose × 1 d	Schistosomiasis cardiac complications including EM-like presentation; CDC + WHO standard regimen
imatinib	100-400 mg PO daily	PO	daily	CURATIVE for FIP1L1-PDGFRA+ HES — dramatic response in days (Cools NEJM 2003 PMID 12660384); preferred over steroids alone for this subset; cardiac monitoring during initiation (rare cardiogenic shock with rapid eosinophil drop in HES)
mepolizumab	300 mg SC q4wk (HES indication); 300 mg SC q4wk (EGPA indication)	SC	q4wk	Steroid-sparing for HES (Roufosse NEJM 2008) + EGPA (MIRRA Wechsler NEJM 2017 PMID 28514601); reduces relapse + steroid burden long-term
cyclophosphamide	750 mg/m² IV monthly × 3-6 mo (EGPA induction) then maintenance with azathioprine or methotrexate	IV	monthly	EULAR/ACR 2021 + NIH protocol — induction therapy for severe EGPA with major organ involvement; cardiac is leading cause of EGPA death
rituximab	375 mg/m² IV weekly × 4 doses (induction) OR 1 g IV q2wk × 2 (alternative)	IV	weekly × 4 or q2wk × 2	RITUXVAS / RAVE protocols for ANCA vasculitis induction; alternative to cyclophosphamide; preferred for fertility preservation
furosemide	40-80 mg IV (diuretic-naive); 2.5x outpatient PO dose IV if on chronic loop (DOSE-trial guided)	IV	q12h titrate	DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; titrate to UOP; transition to PO before discharge
nitroglycerin	5-20 mcg/min IV titrate	IV	continuous	Preload + afterload reduction for hypertensive ADHF; AVOID if SBP <100 or RV-predominant
sacubitril_valsartan	24/26 mg PO BID (titrate to 49/51 then 97/103 BID)	PO	BID	PIONEER-HF PMID 30403955; PARADIGM-HF; 36h washout from ACEi required
carvedilol	3.125 mg PO BID titrate	PO	BID	CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; AHA 2020 myocarditis statement (PMID 32200645) caution during ACTIVE inflammation but standard initiation acceptable per most contemporary practice
spironolactone	12.5-25 mg PO daily	PO	daily	RALES PMID 10471456; monitor K + eGFR; renal dose-adjust
dapagliflozin	10 mg PO daily	PO	daily	DAPA-HF PMID 31535829; 4th pillar GDMT
empagliflozin	10 mg PO daily	PO	daily	EMPULSE PMID 35347356 — in-hospital initiation safe
warfarin	5 mg PO daily INR target 2-3 × 3 mo for mural thrombus	PO	daily	AHA 2022 Class IIa for LV thrombus 3-mo AC; MURAL THROMBUS very common in EM (endocardial damage prothrombotic — Loeffler endocarditis)
apixaban	5 mg PO BID (or 2.5 mg BID per dose-reduction criteria)	PO	BID	ACC/AHA 2023 AFib (PMID 38033089) — DOAC preferred for AF; alternative for mural thrombus per smaller cohorts
amiodarone	150 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min × 18 h	IV	continuous bolus + infusion	AHA 2020 ACLS class IIb; preferred over class I antiarrhythmics in inflamed myocardium (proarrhythmic)
tmp_smx_for_pcp_prophylaxis	160/800 mg PO 3×/wk or 80/400 mg daily	PO	3×/wk or daily	PCP prophylaxis during prolonged high-dose steroid therapy; CDC + IDSA standard

Plan: Eosinophilic myocarditis ADHF (non-shock) — pulse methylprednisolone foundation + etiology-specific targeted therapy + standard ADHF + AC if mural thrombus + GDMT cautiously + MANDATORY strongyloides screen before steroids — ESC 2013 (PMID 23824828) + AHA 2020 (PMID 32200645) + Klion HES guidelines + MIRRA 2017 (PMID 28514601)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent ADHF → admission
Sustained VT → EP + ablation
EF declining despite the four foundational heart-failure medications → advanced HF eval + transplant
Eosinophil count rising on taper → relapse → re-escalate immunosuppression or add mepolizumab
New systemic features → reassess for EGPA flare or HES progression

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Hemodynamic deterioration to SCAI C+ shock (SBP <90 + lactate ≥2 + cool extremities + organ dysfunction) — fulminant EM requires MCS evaluation + emergent EMB(life-threatening)
Patient about to receive steroids without strongyloides screen completed AND endemic exposure history (Latin America, sub-Saharan Africa, SE Asia, immigration, travel) — life-threatening hyperinfection risk if not pre-treated(life-threatening)
Mural thrombus identified on echo (very common in EM — endocardial damage prothrombotic — Loeffler endocarditis) + systemic embolic event (stroke, peripheral arterial embolism, mesenteric, renal)(life-threatening)
Cannot tolerate the four foundational heart-failure medications initiation/up-titration due to hypotension, bradycardia, AKI, or hyperkalemia during active EM inflammation phase + ongoing immunosuppression
Rising peripheral eosinophil count (>1500/µL recurrence) during steroid taper with or without symptom recurrence — relapse of EM
Sustained VT, VF, or high-grade AV block (Mobitz II, complete heart block) during active EM — proarrhythmic substrate from active eosinophilic infiltration(life-threatening)

5. Follow-up

Cardiology at 1-2 wk + 3 + 6 + 12 mo; hematology for HES q3 mo or rheumatology for EGPA; serial echo + cardiac MRI at 3-6 mo; ICD evaluation at 3-6 mo if EF persistently <35; steroid taper guided by eosinophil count + clinical status (typically 6-12 mo total); long-term the four foundational heart-failure medications if persistent HFrEF; relapse surveillance with eosinophil count + symptoms

6. Sources

Guideline: ESC 2013 myocarditis position statement (Caforio PMID 23824828) + AHA 2020 myocarditis scientific statement (Tschöpe PMID 32200645) + 2022 ACC/AHA HF Guideline (Heidenreich PMID 35363499) + Klion HES treatment guidelines + MIRRA EGPA (Wechsler NEJM 2017 PMID 28514601)