This handout is for cardiogenic shock — covid-19-associated myocarditis (infection or post-mrna-vaccine). Your care team identified this based on: acute covid-19 infection (pcr+ within past 4 weeks) with new acute heart failure + cardiogenic shock physiology — acute covid myocarditis with cs.
Other reasons your team may use this plan: recent mrna covid vaccine (pfizer / moderna) within 2-7 days + acute chest pain ± dyspnea ± troponin elevation, especially young male <30 — vaccine-associated myocarditis (usually mild but rarely fulminant); cardiac mri: t2 edema + lge (sub-epicardial / mid-myocardial, often inferolateral in vaccine cases) + abnormal native t1/t2 (≥2 of 3 = lake louise 2018) + recent covid exposure or vaccination; markedly elevated troponin + elevated crp + il-6 + ferritin (cytokine storm pattern) + acute biventricular dysfunction post-covid infection.
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 |
|---|---|---|---|---|
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — NE first-line in CS |
| dobutamine | 2.5 µg/kg/min CAUTIOUS titration; AVOID in ventricular electrical storm | IV | continuous | DOREMI PMID 33704937; CAUTION in inflamed myocardium — escalate to MCS rather than higher inotrope doses |
| tocilizumab | 8 mg/kg IV (max 800 mg) single dose, may repeat × 1 | IV | single dose | REMAP-CAP PMID 33631065 + RECOVERY tocilizumab arm PMID 33933206 — IL-6 receptor blockade in COVID hyperinflammation |
| dexamethasone | 6 mg IV/PO daily × up to 10 days | IV/PO | daily | RECOVERY PMID 32678530 — for concurrent COVID respiratory failure ONLY, NOT trial-evidenced for myocardial involvement; do not use solely for myocarditis |
| nirmatrelvir-ritonavir | 300/100 mg PO BID × 5 days; renal adjust if eGFR 30-60; CI eGFR <30 | PO | BID × 5 d | EPIC-HR PMID 35172054 — early antiviral; CHECK extensive drug interactions |
| ivig | 1-2 g/kg IV total dose (split over 1-2 d) | IV | single course | Robinson Lancet 2020 + uncontrolled case series; pediatric MIS-C IVIG well-established (Belay MMWR 2021); adult RCT lacking but considered in fulminant + MIS-A |
| aspirin | 650-1000 mg PO TID × 1-2 wk then taper | PO | TID | ACC 2022 vaccine myocarditis consensus — NSAID + colchicine for mild vaccine cases; AVOID if fulminant or severe LV dysfunction |
| colchicine | 0.6 mg PO BID × 3 mo | PO | BID | Imazio CORE/CORP-2 (PMID 24168736) for pericarditis; ACC 2022 vaccine myocarditis consensus |
| enoxaparin | 40 mg SC daily prophylactic; 1 mg/kg SC q12h therapeutic | SC | daily/q12h | CHEST 2020 COVID anticoagulation guidance; high VTE risk in COVID |
| amiodarone | 150 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min | IV | continuous | AHA 2020 ACLS Class IIb for refractory VT/VF; high arrhythmia risk in inflamed myocardium |
Plan: COVID-associated myocarditis CS — supportive + cautious inotrope + early MCS bridge to recovery + phenotype-specific (cytokine storm therapy for acute infection; NSAID + colchicine for vaccine-associated mild)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Repeat echo + CMR at 4-8 wks for recovery trajectory; cardiac rehab; the four foundational heart-failure medications 4-pillar if persistent HFrEF; EP follow-up for ICD eligibility; activity restriction × 3-6 mo per AHA 2015 / ESC 2020 sports cardiology + Drezner JACC 2022; vaccine continuation shared decision per CDC ACIP
Guideline: AHA 2022 cardiovascular manifestations of COVID-19 (Gluckman PMID 35403432); ACC 2022 expert consensus on athletes post-COVID; Patone Nat Med 2022 mRNA vaccine-associated myocarditis (PMID 35115708); Caforio ESC 2013 myocarditis position paper (PMID 23824828); Tschöpe AHA 2020 myocarditis scientific statement (PMID 32200645); Ferreira JACC 2018 Lake Louise Criteria 2018 (PMID 30025572)