This handout is for cardiogenic shock — giant cell myocarditis (gcm). Your care team identified this based on: previously healthy young-to-middle-aged adult with rapid (days-to-weeks) progression of acute hf to cardiogenic shock — high suspicion for gcm, especially if associated with vt/vf storm or av block.
Other reasons your team may use this plan: sustained vt/vf storm (≥3 episodes in 24 h) in setting of acute myocarditis — gcm until proven otherwise (50-60% of gcm cases per cooper 1997 + kandolin 2013); emergent emb indication; new high-grade av block (mobitz ii / complete heart block) in acute myocarditis — gcm is the leading clue (15-50% per kandolin 2013); emergent emb indication; endomyocardial biopsy showing multinucleated giant cells (cd68+, s-100−) + lymphocyte infiltrate (t-cell predominant) + myocyte necrosis without non-caseating granulomas (differential vs sarcoidosis) — diagnostic gcm.
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 GCM given high VT/VF risk; escalate to MCS over higher inotrope doses |
| methylprednisolone | 1000 mg IV daily × 3-5 days then prednisone 1 mg/kg/d taper over months | IV | daily | Cooper Multicenter GCM Registry NEJM 1997 (PMID 9197214) + GIANT-2 protocol (PMID 18369191) — cornerstone of combined immunosuppression |
| cyclosporine | 3-5 mg/kg/d divided BID; trough target 200-300 ng/mL acute then 100-200 ng/mL maintenance | PO/IV | BID | Cooper NEJM 1997 + GIANT-2 — combination cyclosporine + steroids markedly improves transplant-free survival from ~10% to ~70%; ESC 2013 myocarditis position paper |
| basiliximab | 20 mg IV day 0 + day 4 (induction) | IV | q4d × 2 doses | GIANT-2 protocol PMID 18369191 — IL-2RA induction in GCM; transplant immunology precedent (basiliximab is standard induction in solid organ transplant) |
| rabbit anti-thymocyte globulin | 1.5 mg/kg/d IV × 5-14 days (induction); replaces historical OKT3 (muromonab) which is no longer available | IV | daily × 5-14 d | Cooper GIANT-2 protocol PMID 18369191 — anti-T-cell induction in GCM; historically OKT3 (muromonab) used but no longer manufactured; ATG is contemporary equivalent |
| azathioprine | 1-2 mg/kg/d PO daily (chronic maintenance) | PO | daily | GIANT-2 protocol PMID 18369191 — chronic maintenance after acute phase; purine antimetabolite |
| mycophenolate mofetil | 1000 mg PO BID (chronic maintenance alternative to AZA) | PO | BID | Solid organ transplant precedent + GIANT-2 — alternative to AZA |
| 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 baseline arrhythmia risk in GCM (50-60%); consider catheter ablation if refractory |
| lidocaine | 1-1.5 mg/kg IV bolus then 1-4 mg/min infusion | IV | continuous | AHA 2020 ACLS alternative for refractory VT/VF |
| magnesium sulfate | 2 g IV bolus over 5-15 min then maintenance to keep Mg ≥2.0 | IV | as needed | AHA 2020 ACLS for torsades; standard electrolyte repletion |
| sulfamethoxazole-trimethoprim | 1 SS tab PO daily or 1 DS tab PO MWF | PO | daily/MWF | PJP prophylaxis on chronic high-dose steroid + cyclosporine; standard transplant immunology |
| valganciclovir | 900 mg PO daily × 3-6 mo per CMV serostatus | PO | daily | CMV prophylaxis on ATG / IL-2RA / chronic immunosuppression; standard transplant immunology |
Plan: Giant cell myocarditis CS — combined immunosuppression per Cooper GIANT-2 protocol (methylprednisolone + cyclosporine + IL-2RA + ATG induction; chronic maintenance with cyclosporine + low-dose steroids + AZA/MMF) + early MCS bridge + transplant listing priority
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; continued combined immunosuppression LIFE-LONG OR until transplant; transplant evaluation completion if not yet listed; cardiac rehab; EP follow-up for ICD eligibility per AHA 2017 VA/SCD guideline (high arrhythmic recurrence — most GCM patients receive ICD after acute phase); post-transplant immunosuppression maintained with surveillance for graft GCM recurrence (20-25% per Kandolin 2013 + Ekström 2024)
Guideline: Cooper Multicenter Giant Cell Myocarditis Registry NEJM 1997 (PMID 9197214); Cooper GIANT-2 trial protocol (PMID 18369191); Caforio ESC 2013 myocarditis position paper (PMID 23824828); Tschöpe AHA 2020 myocarditis scientific statement (PMID 32200645); Cooper AHA/ACC/ESC 2007 EMB consensus (PMID 17998456); Birnie HRS 2014 cardiac sarcoidosis (PMID 24682272) — differential