This handout is for acute hf — viral cardiomyopathy / myocarditis decompensation (non-shock). Your care team identified this based on: recent (1–4 wk) viral prodrome (uri, gi, flu-like) followed by new hf symptoms (dyspnea, orthopnea, edema) + lv dysfunction on echo + elevated troponin → suspect acute viral myocarditis pathway.
Other reasons your team may use this plan: patient with known chronic dilated cardiomyopathy (dcm) attributed to remote viral myocarditis presenting with new adhf (worsening edema, weight gain, nyha iii–iv symptoms) — non-shock spectrum; positive viral pcr (parvovirus b19, coxsackievirus, adenovirus, hhv-6, sars-cov-2, influenza) in serum or np swab + new cardiac dysfunction + troponin elevation; cardiac mri with lake louise criteria 2018 positive (t2 edema mapping + lge non-ischemic pattern + native t1 mapping abnormal) → acute or chronic viral myocarditis.
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 |
|---|---|---|---|---|
| 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 + symptom resolution; transition to PO before discharge |
| nitroglycerin | 5-20 µg/min IV titrate | IV | continuous | Preload + modest afterload reduction for hypertensive ADHF; well-tolerated in viral myocarditis with preserved BP; 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 — in-hospital initiation; PARADIGM-HF — superior to ACEi for HFrEF; 36h washout from ACEi required |
| carvedilol | 3.125 mg PO BID titrate | PO | BID | CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262 — beta-blocker mortality benefit in HFrEF; AHA 2020 myocarditis PMID 32200645 advises CAUTION during ACTIVE inflammation (some experts delay until troponin normalized) but standard initiation acceptable per most contemporary practice |
| spironolactone | 12.5-25 mg PO daily | PO | daily | RALES PMID 10471456 — mortality benefit in HFrEF; monitor K + eGFR; renal dose-adjust |
| dapagliflozin | 10 mg PO daily | PO | daily | DAPA-HF PMID 31535829 — mortality + HF hospitalization benefit; 4th pillar GDMT; safe in active myocarditis (no signal for harm) |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356 — in-hospital initiation safe + improves clinical benefit; alternative to dapagliflozin |
| 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 for sustained VT; preferred over class I antiarrhythmics in inflamed myocardium (class I proarrhythmic in scarred tissue); transition to PO 200 mg daily for chronic suppression |
| warfarin | 5 mg PO daily INR target 2-3 | PO | daily | AHA 2022 Class IIa for LV thrombus 3-mo AC; INR monitoring |
| apixaban | 5 mg PO BID (or 2.5 mg BID per dose-reduction criteria) | PO | BID | ACC/AHA 2023 AFib (PMID 38033089) — DOAC preferred; ARISTOTLE PMID 21870978 |
| oseltamivir | 75 mg PO BID × 5 d | PO | BID | CDC influenza — within 48h symptom onset; benefit primarily systemic (no proven cardiac-specific benefit but reasonable in fluA/B-associated myocarditis) |
| remdesivir | 200 mg IV load × 1 then 100 mg IV daily × 4 d | IV | daily | IDSA COVID-19 — no proven cardiac-specific benefit but reasonable in COVID + cardiac involvement; weigh systemic benefit per current IDSA |
Plan: Viral cardiomyopathy / acute viral myocarditis ADHF (non-shock) — supportive ADHF + cautious GDMT + AVOID NSAIDs (ESC 2013 PMID 23824828; AHA 2020 PMID 32200645; 2022 ACC/AHA HF PMID 35363499)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology follow-up at 1–2 wk + 3 mo + 6 mo + 12 mo; serial echo + cardiac MRI at 3–6 mo; ICD evaluation at 3–6 mo if EF persistently <35; transplant referral if end-stage despite optimized the four foundational heart-failure medications; activity clearance for return-to-play after 3–6 mo + normal echo + MRI + exercise stress test + holter (per Maron 2015 PMID 26621650 sports cardiology)
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) + Lake Louise 2018 (Ferreira PMID 30217631)