This handout is for cardiogenic shock — fulminant viral / immune myocarditis. Your care team identified this based on: recent viral prodrome (uri / gi illness in past 1–4 wks) followed by acute heart failure + cardiogenic shock physiology — fulminant myocarditis with cs.
Other reasons your team may use this plan: 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; recent ici exposure (anti-pd1/l1, anti-ctla4) within past 12 weeks + acute hf + ↑ troponin → ici myocarditis, often fulminant; markedly elevated troponin + acute biventricular dysfunction + no obstructive cad on cath → myocarditis differential.
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 — non-inferior to milrinone; CAUTION in inflamed myocardium given high arrhythmia risk; escalate to MCS rather than higher inotrope doses |
| methylprednisolone | 1000 mg IV daily × 3–5 days, then 1 mg/kg/d taper | IV | daily | AHA 2024 ICI cardiotoxicity statement — high-dose pulse steroids for ICI myocarditis; ESC 2013 myocarditis position paper for eosinophilic / giant cell |
| cyclosporine | 3–5 mg/kg/d divided BID; trough target 200–300 ng/mL | PO/IV | BID | Cooper Multicenter Giant Cell Myocarditis Registry NEJM 1997 — combination cyclosporine + steroids markedly improves transplant-free survival vs no immunosuppression (~70% vs ~10%); ESC 2013 myocarditis position paper |
| abatacept | 500–1000 mg IV q2 wks × multiple doses per refractory ICI myocarditis protocol | IV | q2 weeks | Salem JACC 2018 + AHA 2024 ICI cardiotoxicity statement — abatacept for steroid-refractory ICI myocarditis; CTLA4-Ig blunts T-cell activation |
| infliximab | 5 mg/kg IV | IV | single dose, may repeat | AHA 2024 ICI cardiotoxicity statement — alternative to abatacept; CONTRAINDICATED if EF <35 (TNF inhibitor worsens HF per ATTACH NEJM 2003) |
| phenylephrine | 40–360 µg/min IV | IV | continuous | Pure α-pressor; alternative when β-stimulation aggravates arrhythmias in inflamed myocardium |
| 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 |
| metformin | AVOID NSAIDs | n/a | n/a | AVOID NSAIDs — animal models worsen myocarditis (ESC 2013 position paper); listed as a contraindication marker rather than a drug |
Plan: Fulminant myocarditis CS — supportive + cautious inotrope (high arrhythmia risk) + early MCS bridge to recovery + sub-etiology-specific immunosuppression
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 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
Guideline: Caforio ESC 2013 myocarditis position paper (PMID 23824828); Tschöpe AHA 2020 myocarditis scientific statement (PMID 32200645); AHA 2024 ICI cardiotoxicity scientific statement; Cooper Multicenter Giant Cell Myocarditis Registry NEJM 1997; McCarthy NEJM 2000 fulminant vs non-fulminant outcomes (PMID 10717012); Ferreira JACC 2018 Lake Louise Criteria 2018 (PMID 30025572)