Clinical Commander

All dossiers
cardio.cardiogenic-shock.viral-myocarditis.v1

Cardiogenic shock — fulminant viral / immune myocarditis

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to fulminant viral / immune myocarditis with cardiogenic shock per Caforio ESC 2013 myocarditis position paper (PMID 23824828) + Tschöpe AHA 2020 myocarditis scientific statement (PMID 32200645). Etiology spectrum: viral (parvovirus B19, HHV-6, enterovirus, adenovirus, COVID-19); giant cell (near-100% mortality without immunosuppression); eosinophilic; autoimmune (SLE, sarcoidosis, EGPA); ICI-induced (anti-PD1/L1, anti-CTLA4) per AHA 2024 ICI cardiotoxicity statement. Workup pivots from standard CS: CMR with Lake Louise 2018 criteria (Ferreira JACC 2018 PMID 30025572) — T2 edema + LGE + abnormal native T1/T2 (≥2 of 3); endomyocardial biopsy GOLD STANDARD per AHA/ACC/ESC 2007 (Cooper PMID 17998456) when life-threatening (giant cell, eosinophilic, ICI need diagnosis-changing immunosuppression); viral PCR panel (does not change management in adults). Treatment ACUTE: standard CS support (NE first-line per SOAP-II PMID 20200382); inotropes CAUTIOUS in inflamed myocardium (high arrhythmia risk — escalate to MCS rather than higher inotropes); MCS bridge (IABP / Impella / VA-ECMO) early — fulminant viral has high recovery rate (McCarthy NEJM 2000 PMID 10717012); ELSO 2020 ECMO myocarditis registry 60–70% survival to discharge. Etiology-specific: giant cell → high-dose methylprednisolone + cyclosporine ± OKT3 (transplant-free survival ~70% vs ~10% per Cooper NEJM 1997); eosinophilic → corticosteroids; ICI → methylprednisolone 1g IV daily + abatacept (CTLA4-Ig) ± infliximab (CONTRAINDICATED if EF<35); viral → supportive only (no antiviral / IVIG benefit in adults per Mason 1995 + McNamara IMAC-2). AVOID NSAIDs (worsen myocarditis per ESC 2013). Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for inflammatory etiology — CMR + EMB diagnostic pathway, sub-etiology-specific immunosuppression, MCS bridge to recovery given high recovery rate in fulminant viral, lifelong NSAID avoidance, ICI rechallenge contraindication after fulminant. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 10 etiology variant.

Entry points (5)

  • symptom
    Recent viral prodrome (URI / GI illness in past 1–4 wks) followed by acute heart failure + cardiogenic shock physiology — fulminant myocarditis with CS
    recent_viral_prodrome_with_acute_hf_and_shock
  • imaging
    Cardiac MRI: T2 edema + LGE (non-ischemic pattern, sub-epicardial / mid-myocardial) + abnormal native T1/T2 mapping (≥2 of 3 = Lake Louise 2018) + biventricular dysfunction + shock physiology
    cmr_lake_louise_criteria_with_shock
  • history
    Recent ICI exposure (anti-PD1/L1, anti-CTLA4) within past 12 weeks + acute HF + ↑ troponin → ICI myocarditis, often fulminant
    recent_immune_checkpoint_inhibitor_with_acute_hf
  • lab_abnormality
    Markedly elevated troponin + acute biventricular dysfunction + NO obstructive CAD on cath → myocarditis differential
    troponin_elevated_with_acute_lv_dysfunction_no_obstructive_cad
  • lab_abnormality
    Peripheral eosinophilia (>1500 / µL) + acute HF + recent drug exposure / parasitic risk → eosinophilic myocarditis suspect
    peripheral_eosinophilia_with_acute_hf

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Younger patients (often <50) over-represented in fulminant viral myocarditis; ICI myocarditis in oncology population; informs prognosis and recovery candidacy
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; gates vasopressor escalation
  • hrrequired
    vital • used at CONTEXT
    Tachyarrhythmia / heart block common in inflamed myocardium; AV block is a giant-cell myocarditis clue
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Markedly elevated; trend correlates with severity; persistent elevation suggests ongoing myocyte injury
  • bnp_ntprobnprequired
    lab • used at INITIAL_WORKUP
    Acute HF marker; trend tracks recovery
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging + response to therapy; CardShock prognostication (Harjola EHJ 2015 PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker + dose adjustment for supportive medications; gadolinium contrast safety for CMR
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Eosinophil count is the eosinophilic-myocarditis screen; lymphopenia in some viral cases
  • viral_pcr_panel
    lab • used at BRANCHING_WORKUP
    Parvovirus B19, HHV-6, enterovirus, adenovirus, SARS-CoV-2, EBV — informs viral etiology though does not change supportive-care strategy in adults
  • echorequired
    imaging • used at INITIAL_WORKUP
    Biventricular dysfunction; absence of regional wall motion abnormality crossing single coronary territory; pericardial effusion in 30–50%
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    New AV block in giant cell myocarditis (~50%); diffuse ST/T-wave changes; PR depression if pericarditis overlap
  • cor_angiorequired
    imaging • used at BRANCHING_WORKUP
    Mandatory rule-out of obstructive CAD (mimics acute MI); typically clean coronaries in myocarditis
  • cmrrequired
    imaging • used at BRANCHING_WORKUP
    Lake Louise Criteria 2018 (Ferreira PMID 30025572) — T2 edema + LGE (non-ischemic sub-epicardial / mid-myocardial) + abnormal native T1/T2 mapping (≥2 of 3); preferred non-invasive diagnostic
  • endomyocardial_biopsy
    imaging • used at BRANCHING_WORKUP
    GOLD STANDARD when life-threatening per AHA/ACC/ESC 2007 EMB consensus (Cooper PMID 17998456); essential when giant cell, eosinophilic, ICI suspected because diagnosis changes immunosuppression decision
  • recent_viral_prodromerequired
    history • used at CONTEXT
    Recent URI / GI illness in past 1–4 wks supports viral etiology
  • recent_ici_exposurerequired
    medication • used at CONTEXT
    Anti-PD1/L1 / anti-CTLA4 within past 12 wks → ICI myocarditis differential; mandates high-dose steroids + abatacept consideration

12-phase flow (11)

  1. 1FRAME
    Confirm fulminant myocarditis as the cardiogenic shock etiology — recent viral prodrome OR ICI exposure OR eosinophilia OR new AV block, with biventricular dysfunction and no obstructive CAD; identify suspected sub-etiology (viral vs giant cell vs eosinophilic vs ICI vs autoimmune) which drives diagnostic urgency for EMB
    inputs: echo, cor_angio
    advance: Myocarditis confirmed and sub-etiology hypothesis stated
  2. 2ENTRY
    CS team activation; emergency cath to exclude obstructive CAD (mandatory MI mimic rule-out); echo for biventricular function and effusion; mobilize MCS team early — fulminant myocarditis has high recovery rate if bridged through initial period
    inputs: sbp, lactate
    advance: CS team activated + obstructive CAD excluded + MCS team aware
  3. 3CONTEXT
    Recent viral prodrome, ICI exposure, autoimmune disease history (SLE, sarcoidosis, EGPA), drug history (eosinophilic trigger), arrhythmia history, code status
    inputs: hr, creatinine, recent_viral_prodrome, recent_ici_exposure
    advance: Context complete and sub-etiology working hypothesis stated
  4. 4RED_FLAGS
    Ventricular electrical storm (sustained VT/VF in inflamed myocardium — exceptionally arrhythmogenic); high-grade AV block (giant cell myocarditis clue → emergent EMB indication); refractory shock (escalate to MCS rather than higher inotropes); cardiac tamponade if large pericardial effusion
    inputs: sbp, hr
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Arrhythmia and tamponade screened, MCS pathway engaged if needed
  5. 5INITIAL_WORKUP
    ECG (AV block, diffuse ST/T-wave changes), echo (biventricular dysfunction, effusion), troponin, BNP, BMP, lactate, CBC w/ diff (eosinophil count), CXR; serial telemetry; SCAI 2022 staging
    inputs: ecg, echo, troponin, bnp_ntprobnp, lactate, cbc_with_diff
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg, panel.cbc
    advance: Workup complete and SCAI stage assigned
  6. 6BRANCHING_WORKUP
    Cardiac MRI (Lake Louise 2018 criteria) when stable enough for transport; emergency angiography to rule out obstructive CAD; endomyocardial biopsy if life-threatening (giant cell, eosinophilic, ICI suspected — diagnosis changes immunosuppression); viral PCR panel; tryptase + IgE if eosinophilic suspect; autoimmune serologies (ANA, ANCA, dsDNA) if autoimmune clue
    inputs: cor_angio, cmr
    advance: Sub-etiology confirmed by CMR ± EMB
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; sub-etiology drives prognosis (giant cell ~70% transplant-free survival WITH immunosuppression vs ~10% without; ICI fulminant 25–50% mortality; viral non-fulminant LV recovery in 50–60%; fulminant viral has paradoxically BETTER long-term survival than non-fulminant per McCarthy NEJM 2000 PMID 10717012 if patient survives initial period)
    inputs: sbp, lactate, troponin
    advance: Risk stratified and recovery candidacy assessed
  8. 8TREATMENT
    Standard CS support (NE first-line per SOAP-II); inotropes CAUTIOUS in inflamed myocardium (arrhythmia risk — escalate to MCS rather than higher inotropes); MCS bridge (IABP / Impella / VA-ECMO) early since fulminant viral has high recovery rate; etiology-specific: giant cell → high-dose steroids + cyclosporine; eosinophilic → corticosteroids; ICI → methylprednisolone 1g IV daily + abatacept / infliximab (avoid infliximab in EF<35); viral → supportive only; AVOID NSAIDs
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Sub-etiology-appropriate immunosuppression started (or supportive if viral) + MCS plan documented
  9. 9DISPOSITION
    CICU at MCS-capable / transplant-capable center; advanced HF + transplant evaluation if refractory; arrhythmia management with EP
    advance: Disposition assigned with MDT mobilised (cards, IC, advanced HF, transplant, EP, oncology if ICI)
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output; continuous telemetry (high arrhythmia risk); serial echo q24h for LV recovery trajectory; daily troponin and BNP; serial ECG for AV block evolution; daily CBC with diff if immunosuppression
    inputs: lactate, troponin
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence set + reassessment scheduled
  11. 11FOLLOWUP
    Repeat echo + CMR at 4–8 wks for recovery trajectory; cardiac rehab; GDMT 4-pillar if persistent HFrEF; EP follow-up for ICD eligibility per AHA 2017 VA/SCD guideline (waiting period before ICD given recovery potential); psych / oncology follow-up; ICI rechallenge generally CONTRAINDICATED after fulminant ICI myocarditis
    advance: Recovery echo, CMR, GDMT, ICD eligibility timeline booked