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cardio.cardiogenic-shock.bacterial-myocarditis.v1PRODUCTION
cardio.cardiogenic-shock.bacterial-myocarditis.v1

Cardiogenic shock — bacterial myocarditis (Staph, Strep, diphtheria, TB, meningococcal)

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Bacterial myocarditis with cardiogenic shock — distinct from viral / autoimmune / Lyme by bacterial pathogen + targeted antibiotic therapy + AVOIDANCE of immunosuppression; identify etiology subgroup (Staph/Strep/diphtheria/TB/meningococcal/atypical) for tailored regimen

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Bacterial myocarditis confirmed as working diagnosis with etiologic subgroup identified or empiric coverage started

Patient inputs (22)

Bacterial myocarditis can affect any age; diphtheria classic in <5 y or unvaccinated adults; TB more common in older / immunocompromised

Baseline for vancomycin trough monitoring + nephrotoxic agent dosing; AKI common in mixed shock

TB drug hepatotoxicity baseline; sepsis-related transaminitis; congestive hepatopathy from RV dysfunction

Diphtheria + meningococcal + pneumococcal + COVID-19 status drives risk; gaps suggest preventable etiology

Drives antibiotic selection — vancomycin alone if anaphylactic to beta-lactams; daptomycin alternative

Pulm congestion from LV dysfunction + ARDS from sepsis; intubation often needed

Elevated in active myocarditis; trend during recovery; pseudo-MI pattern possible

Elevated proportional to LV dysfunction; trends recovery on antibiotics

MANDATORY × 3 BEFORE antibiotics — identifies organism + drives targeted therapy; modified Duke criteria for endocarditis exclusion

Leukocytosis + left shift in bacterial; thrombocytopenia in TB / meningococcal / sepsis-DIC

Pseudo-MI ST changes, AV block (diphtheria / TB / Lyme overlap), arrhythmia; serial monitoring

LV function, RV strain, pericardial effusion (TB, meningococcal), valvular function (rule out IE), wall motion

Pulm congestion + cavitary lesions if TB + cardiomegaly + pericardial effusion silhouette

SCAI 2022 staging baseline; bacterial myocarditis CS often combined with septic shock — distributive + cardiogenic mixed picture

Tachycardia from sepsis + LV dysfunction; AV block in diphtheria / Lyme / TB myocarditis with conduction system involvement

Fever almost always present in active bacterial myocarditis; temp >38.5 = SIRS criterion + sepsis bundle activation

SCAI staging anchor + sepsis bundle marker; ≥2 = SCAI C+; ≥4 = severe shock

TB risk + immunocompromised classification; TB myocarditis more common in HIV+; affects treatment intensity

TB myocarditis screen if subacute presentation + endemic exposure / immunocompromised

Lake Louise criteria (T2/T1 mapping + LGE) for myocarditis confirmation + prognostication

Endemic region, household contact, prior treatment, BCG history; HIV co-infection risk

Atypicals — Coxiella (livestock), Brucella (unpasteurized dairy), Leptospira (water/rodents), Rickettsia (ticks/fleas)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningsepsis_bundle_delay_with_bacterial_myocarditis_cs
    Failure to start sepsis bundle (cultures + abx within 1 h) in bacterial myocarditis CS — every hour of antibiotic delay associated with ~7-8% mortality increase
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningimmunosuppression_error_in_bacterial_vs_autoimmune_myocarditis_confusion
    Steroids / immunosuppression mistakenly initiated in bacterial myocarditis (mistaking for autoimmune / giant-cell myocarditis) — worsens infection, sepsis progression
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdiphtheria_antitoxin_window_emergent_cdc_contact
    Diphtheria suspicion → CDC stockpile equine antitoxin contact emergent; antitoxin only effective before tissue binding; do NOT delay for confirmation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmeningococcal_sepsis_with_waterhouse_friderichsen_adrenal_crisis
    Meningococcemia with bilateral adrenal hemorrhage (Waterhouse-Friderichsen) → adrenal crisis + DIC + purpura fulminans + bacterial myocarditis component
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevaccination_history_failure_diphtheria_meningococcal_pneumococcal
    Bacterial myocarditis traced to vaccine-preventable etiology in unvaccinated / under-vaccinated patient — diphtheria, meningococcal, pneumococcal, Hib; family / contact tracing + emergent vaccination
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremdr_organism_resistance_or_treatment_failure
    Multidrug-resistant organism (MRSA with reduced vancomycin susceptibility, MDR-TB, ESBL Strep) → treatment failure on initial empiric regimen
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Bacterial myocarditis CS — targeted antibiotics by organism + standard CS support; AVOID immunosuppression (distinct from autoimmune myocarditis)
axis: bacterial_myocarditis_cs_targeted_antibiotics_phenotype
Selected axis "Bacterial myocarditis CS — targeted antibiotics by organism + standard CS support; AVOID immunosuppression (distinct from autoimmune myocarditis)" by default fallback (first axis)
  • vancomycin
    first line
    glycopeptide
    25-30 mg/kg IV load then 15-20 mg/kg q8-12h titrate trough 15-20 µg/mL • IV • q8-12h
    triggers: empiric_bacterial_myocarditis_with_cs, mrsa_coverage_needed, staph_strep_coverage
    IDSA MRSA + AHA 2015 endocarditis (Baddour PMID 26373316) — first-line for MSSA/MRSA/Strep coverage in bacterial myocarditis with bacteremia; trough monitoring for nephrotoxicity
    rxcui 11124
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV q24h (q12h for meningitis) • IV • q24h
    triggers: empiric_bacterial_myocarditis_with_cs, meningococcal_disease, streptococcal_coverage
    Empiric coverage for Strep, meningococcal, susceptible Staph; first-line for meningococcal myocarditis + meningitis (CDC 2024 guidance)
    rxcui 2193
  • piperacillin-tazobactam
    second line
    beta_lactam_beta_lactamase_inhibitor
    4.5 g IV q6-8h • IV • q6-8h
    triggers: hcap_risk_with_bacterial_myocarditis, broad_spectrum_needed, pseudomonas_risk
    Broader-spectrum empiric if HCAP / nosocomial source / pseudomonas risk; alternative to ceftriaxone
    rxcui 74169
  • oxacillin
    comorbidity specific
    antistaphylococcal_penicillin
    2 g IV q4h • IV • q4h
    triggers: mssa_confirmed_on_culture
    AHA 2015 endocarditis — anti-staphylococcal penicillin preferred for MSSA over vancomycin (better outcomes); narrow spectrum after culture confirms MSSA
    rxcui 7773
  • cefazolin
    comorbidity specific
    cephalosporin_1st_gen
    2 g IV q8h • IV • q8h
    triggers: mssa_with_mild_penicillin_allergy, cardiac_surgery_prep
    AHA 2015 endocarditis alternative to oxacillin for MSSA with mild PCN allergy; also for cardiac surgery prep if MCS
    rxcui 2180
  • doxycycline
    comorbidity specific
    tetracycline
    100 mg PO/IV BID • PO/IV • BID
    triggers: atypical_pathogen_coverage, rickettsia_coxiella_chlamydia, lyme_overlap_consideration
    Atypicals (Coxiella Q-fever, Rickettsia, Chlamydia, Lyme overlap); IDSA 2021 Lyme PMID 33417672
    rxcui 3640
  • erythromycin
    rescue
    macrolide
    500 mg IV q6h × 14 days • IV • q6h
    triggers: diphtheria_confirmed_or_high_suspicion, mycoplasma_chlamydia_atypical
    CDC diphtheria guidance — erythromycin or penicillin G for diphtheria; eradicate carriage; reduce toxin burden
    rxcui 4053
  • penicillin g
    rescue
    natural_penicillin
    2-4 million units IV q4h × 14 days • IV • q4h
    triggers: diphtheria_confirmed, rheumatic_carditis_with_strep
    CDC diphtheria + rheumatic carditis — penicillin G eradicates organism; for diphtheria, antitoxin is the primary therapy and antibiotics secondary
    rxcui 7980
  • rifampin
    comorbidity specific
    antimycobacterial_rifamycin
    600 mg PO daily • PO • daily
    triggers: tb_myocarditis_confirmed, ripe_protocol
    WHO TB 2023 RIPE protocol — rifampin core agent; 2 mo intensive then 4 mo continuation
    rxcui 9384
  • isoniazid
    comorbidity specific
    antimycobacterial_inh
    300 mg PO daily + pyridoxine 25 mg • PO • daily
    triggers: tb_myocarditis_confirmed, ripe_protocol
    WHO TB 2023 RIPE protocol — INH core agent with pyridoxine for neuropathy prevention
    rxcui 6038
  • pyrazinamide
    comorbidity specific
    antimycobacterial_pza
    15-30 mg/kg PO daily (max 2 g) • PO • daily
    triggers: tb_myocarditis_confirmed_first_2_months, ripe_protocol_intensive_phase
    WHO TB 2023 RIPE intensive phase × 2 mo; hepatotoxicity surveillance required
    rxcui 8987
  • ethambutol
    comorbidity specific
    antimycobacterial_emb
    15-25 mg/kg PO daily • PO • daily
    triggers: tb_myocarditis_confirmed_first_2_months, ripe_protocol_intensive_phase, drug_resistance_uncertain
    WHO TB 2023 RIPE intensive phase × 2 mo; ophthalmology baseline for optic neuritis monitoring
    rxcui 4110
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: bacterial_myocarditis_cs_with_sbp_lt_90, mixed_septic_cardiogenic_shock
    SOAP-II PMID 20200382 — NE first-line in CS + septic shock; preferred over dopamine
    rxcui 7512
  • dobutamine
    second line
    inotrope_beta1
    2.5–10 µg/kg/min titrate • IV • continuous
    triggers: low_cardiac_output_with_bacterial_myocarditis, lv_dysfunction_with_shock_after_resuscitation
    CAUTIOUS in active myocarditis — arrhythmogenic; use only if persistent low CO after volume + NE optimization
    rxcui 3616
  • dexamethasone
    rescue
    corticosteroid
    0.15 mg/kg IV q6h × 4 days (meningitis adjunct) • IV • q6h
    triggers: meningococcal_meningitis_concurrent, rheumatic_carditis_severe, tb_pericarditis_component
    IDSA meningitis — dexamethasone with first dose of antibiotics in pneumococcal/meningococcal meningitis; AVOID routine immunosuppression in bacterial myocarditis (worsens infection — distinct from autoimmune myocarditis)
    rxcui 3264

outpatient playbook — drug actions (3)

  1. 1. continue GDMT 4-pillar if persistent EF<40
    rxcui 593411
    empagliflozin 10 mg + carvedilol + ARNi/ACEi + MRA at max tolerated • PO • as scheduled
    trigger: Persistent EF<40 from myocarditis
    EMPULSE PMID 35347356; ACC/AHA 2022 HF Class I
  2. 2. taper GDMT if EF recovered
    gradual taper if EF normalized for ≥6 months • PO • as scheduled
    trigger: Sustained LV recovery
    Many bacterial myocarditis fully recover; GDMT often time-limited unlike chronic HFrEF
  3. 3. complete TB RIPE / continuation phase
    rxcui 9384
    rifampin + INH × 4 mo continuation • PO • daily
    trigger: TB myocarditis confirmed
    WHO TB 2023

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cardiogenic shock + fever + signs of bacteremia → bacterial myocarditis suspicion (Staph, Strep, meningococcal); Recent severe pharyngitis (gray membrane) in unvaccinated patient + new carditis → diphtheria toxin myocarditis (medical emergency, antitoxin from CDC); Subacute carditis + constitutional symptoms + pericardial effusion in HIV-positive / immunocompromised → TB myocarditis evaluation.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — bacterial myocarditis (Staph, Strep, diphtheria, TB, meningococcal)** (cardio.cardiogenic-shock.bacterial-myocarditis.v1).
Phenotype framing: Bacterial subgroup identified (Staph vs Strep vs diphtheria vs TB vs meningococcal vs atypical); rule out viral (PCR), autoimmune (giant cell — EMB), drug-induced (clozapine, ICI), infiltrative (amyloid, sarcoid)
Scope: Bacterial myocarditis with cardiogenic shock — distinct from viral / autoimmune / Lyme by bacterial pathogen + targeted antibiotic therapy + AVOIDANCE of immunosuppression; identify etiology subgroup (Staph/Strep/diphtheria/TB/meningococcal/atypical) for tailored regimen

No severity triggers fired against current inputs.

Plan

Regimen axis: **Bacterial myocarditis CS — targeted antibiotics by organism + standard CS support; AVOID immunosuppression (distinct from autoimmune myocarditis)**.
1. vancomycin 25-30 mg/kg IV load then 15-20 mg/kg q8-12h titrate trough 15-20 µg/mL IV q8-12h (glycopeptide, first line) — IDSA MRSA + AHA 2015 endocarditis (Baddour PMID 26373316) — first-line for MSSA/MRSA/Strep coverage in bacterial myocarditis with bacteremia; trough monitoring for nephrotoxicity
2. ceftriaxone 2 g IV q24h (q12h for meningitis) IV q24h (cephalosporin_3rd_gen, first line) — Empiric coverage for Strep, meningococcal, susceptible Staph; first-line for meningococcal myocarditis + meningitis (CDC 2024 guidance)
3. piperacillin-tazobactam 4.5 g IV q6-8h IV q6-8h (beta_lactam_beta_lactamase_inhibitor, second line) — Broader-spectrum empiric if HCAP / nosocomial source / pseudomonas risk; alternative to ceftriaxone
4. oxacillin 2 g IV q4h IV q4h (antistaphylococcal_penicillin, comorbidity specific) — AHA 2015 endocarditis — anti-staphylococcal penicillin preferred for MSSA over vancomycin (better outcomes); narrow spectrum after culture confirms MSSA
5. cefazolin 2 g IV q8h IV q8h (cephalosporin_1st_gen, comorbidity specific) — AHA 2015 endocarditis alternative to oxacillin for MSSA with mild PCN allergy; also for cardiac surgery prep if MCS
6. doxycycline 100 mg PO/IV BID PO/IV BID (tetracycline, comorbidity specific) — Atypicals (Coxiella Q-fever, Rickettsia, Chlamydia, Lyme overlap); IDSA 2021 Lyme PMID 33417672
7. erythromycin 500 mg IV q6h × 14 days IV q6h (macrolide, rescue) — CDC diphtheria guidance — erythromycin or penicillin G for diphtheria; eradicate carriage; reduce toxin burden
8. penicillin g 2-4 million units IV q4h × 14 days IV q4h (natural_penicillin, rescue) — CDC diphtheria + rheumatic carditis — penicillin G eradicates organism; for diphtheria, antitoxin is the primary therapy and antibiotics secondary
9. rifampin 600 mg PO daily PO daily (antimycobacterial_rifamycin, comorbidity specific) — WHO TB 2023 RIPE protocol — rifampin core agent; 2 mo intensive then 4 mo continuation
10. isoniazid 300 mg PO daily + pyridoxine 25 mg PO daily (antimycobacterial_inh, comorbidity specific) — WHO TB 2023 RIPE protocol — INH core agent with pyridoxine for neuropathy prevention
11. pyrazinamide 15-30 mg/kg PO daily (max 2 g) PO daily (antimycobacterial_pza, comorbidity specific) — WHO TB 2023 RIPE intensive phase × 2 mo; hepatotoxicity surveillance required
12. ethambutol 15-25 mg/kg PO daily PO daily (antimycobacterial_emb, comorbidity specific) — WHO TB 2023 RIPE intensive phase × 2 mo; ophthalmology baseline for optic neuritis monitoring
13. norepinephrine 0.05–0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha, first line) — SOAP-II PMID 20200382 — NE first-line in CS + septic shock; preferred over dopamine
14. dobutamine 2.5–10 µg/kg/min titrate IV continuous (inotrope_beta1, second line) — CAUTIOUS in active myocarditis — arrhythmogenic; use only if persistent low CO after volume + NE optimization
15. dexamethasone 0.15 mg/kg IV q6h × 4 days (meningitis adjunct) IV q6h (corticosteroid, rescue) — IDSA meningitis — dexamethasone with first dose of antibiotics in pneumococcal/meningococcal meningitis; AVOID routine immunosuppression in bacterial myocarditis (worsens infection — distinct from autoimmune myocarditis)

Setting playbook (outpatient) — 1-3 months follow-up — confirm sustained recovery on cardiac MRI (fibrosis assessment); GDMT continuation if persistent EF<40; complete TB therapy if applicable; vaccination maintenance; family screening; cardiac rehab completion
16. continue GDMT 4-pillar if persistent EF<40 empagliflozin 10 mg + carvedilol + ARNi/ACEi + MRA at max tolerated PO as scheduled — Persistent EF<40 from myocarditis (EMPULSE PMID 35347356; ACC/AHA 2022 HF Class I)
17. taper GDMT if EF recovered gradual taper if EF normalized for ≥6 months PO as scheduled — Sustained LV recovery (Many bacterial myocarditis fully recover; GDMT often time-limited unlike chronic HFrEF)
18. complete TB RIPE / continuation phase rifampin + INH × 4 mo continuation PO daily — TB myocarditis confirmed (WHO TB 2023)

Non-pharmacologic actions:
- Annual influenza + pneumococcal + COVID-19 + diphtheria booster if due (Tdap q10y)
- Meningococcal vaccination if at-risk (asplenia, complement deficiency, military, college dorm)
- Cardiac rehab maintenance phase
- Family screening / vaccination if outbreak organism (diphtheria, meningococcal, TB)
- Cardiology + ID quarterly visit
- TB DOT completion if TB

AVOID / contraindication checks:
- Routine_immunosuppression_AVOID_in_bacterial_myocarditis (distinct from autoimmune myocarditis — worsens infection per ESC 2013 PMID 23824828 + AHA 2020 PMID 32200645)
- Vancomycin_dose_adjust_in_renal_impairment (trough 15 20 µg/mL; nephrotoxicity surveillance)
- Ceftriaxone_caution_severe_penicillin_anaphylaxis (~1 2% cross reactivity; vancomycin alone if severe)
- Doxycycline_avoid_in_pregnancy_and_children_under_8 (tooth staining + bone effects)
- Ripe_hepatotoxicity_surveillance (LFT q2 4 weeks; hold if AST/ALT >3x ULN with symptoms)
- Ethambutol_ophthalmology_baseline_and_monthly (optic neuritis surveillance)
- Dobutamine_arrhythmogenic_caution_in_active_myocarditis (use only after NE + volume optimization)
- Diphtheria_antitoxin_horse_serum_anaphylaxis_risk (skin testing recommended; CDC stockpile only)
- Meningococcal_close_contact_chemoprophylaxis_within_24h (rifampin or ciprofloxacin per CDC 2024)
- Tb_isolation_negative_pressure_room_mandatory (until 3 negative AFB sputums)

Monitoring

Regimen monitoring:
- continuous hemodynamics in cicu
- daily lactate clearance trajectory
- daily troponin and BNP trend
- repeat blood cultures at 48-72h to confirm clearance
- vancomycin trough q3-5 doses during titration
- BMP and creatinine daily for vancomycin nephrotoxicity
- LFT q2-4 weeks during RIPE TB therapy
- ophthalmology monthly during ethambutol
- CBC with diff q weekly during antibiotics
- echo at 48-72h then at d/c for LV recovery
- cardiac MRI at 3-6 months for fibrosis assessment
- CK creatinine for daptomycin if used
- contact tracing for diphtheria meningococcal TB within 24-72h
- vaccination status review post recovery diphtheria pneumo meningo

Setting (outpatient) monitoring:
- Quarterly clinical + labs
- Annual echo + cardiac MRI follow-up at 3-6 mo for fibrosis
- TB clinic monthly during RIPE
- Family contact tracing follow-up

Follow-up plan: Cardiology + ID follow-up at 1-3 mo; cardiac MRI at 3-6 mo for fibrosis assessment + recovery confirmation; vaccination updates (diphtheria booster q10y; pneumococcal; meningococcal if at-risk); GDMT continuation if persistent EF<40; cardiac rehab; contact tracing for diphtheria / meningococcal / TB
- Close-out criterion: Follow-up booked + recovery confirmation imaging scheduled + contact tracing initiated

Monitoring phase: Continuous hemodynamics, daily lactate clearance, daily troponin + BNP trend, repeat blood cultures at 48-72 h to confirm clearance, daily BMP + LFT during antibiotics, vancomycin trough levels, AST/ALT during TB therapy, GDMT initiation if persistent EF<40 once euvolemic + off pressors ≥24 h

Disposition

Current setting: outpatient — 1-3 months follow-up — confirm sustained recovery on cardiac MRI (fibrosis assessment); GDMT continuation if persistent EF<40; complete TB therapy if applicable; vaccination maintenance; family screening; cardiac rehab completion

Disposition criteria:
- Sustained recovery + completed antibiotic course + vaccinations updated → annual primary care follow-up only
- Persistent abnormality / chronic HFrEF → continued cardiology / ID specialist follow-up

Escalation triggers (move to higher acuity):
- Recurrent shock or new arrhythmia → ED + CICU
- TB drug resistance → MDR-TB regimen + ID
- New bacteremia / fever → ID + endocarditis re-workup
- Persistent EF<40 at 6 months → cardiology long-term + chronic HFrEF management
- Cardiac MRI fibrosis progression → advanced HF evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Failure to start sepsis bundle (cultures + abx within 1 h) in bacterial myocarditis CS — every hour of antibiotic delay associated with ~7-8% mortality increase
- [LIFE_THREATENING] Steroids / immunosuppression mistakenly initiated in bacterial myocarditis (mistaking for autoimmune / giant-cell myocarditis) — worsens infection, sepsis progression
- [LIFE_THREATENING] Diphtheria suspicion → CDC stockpile equine antitoxin contact emergent; antitoxin only effective before tissue binding; do NOT delay for confirmation

Citations

- ESC 2013 myocarditis position statement (Caforio PMID 23824828); AHA 2020 Scientific Statement on Acute Myocarditis (PMID 32200645); CDC Diphtheria Clinical Guidance + 2024 vaccination schedule; CDC Meningococcal Disease Guidance + 2024 vaccination schedule; IDSA Lyme 2021 (Lantos PMID 33417672); WHO TB 2023; SCAI 2022 CS staging (Naidu PMID 35718438); SSC 2026 sepsis bundle [PMID:23824828](https://pubmed.ncbi.nlm.nih.gov/23824828/)
- Cited evidence (PMID 32200645) [PMID:32200645](https://pubmed.ncbi.nlm.nih.gov/32200645/)
- Cited evidence (PMID 33417672) [PMID:33417672](https://pubmed.ncbi.nlm.nih.gov/33417672/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ESC 2013 myocarditis position statement (Caforio PMID 23824828); AHA 2020 Scientific Statement on Acute Myocarditis (PMID 32200645); CDC Diphtheria Clinical Guidance + 2024 vaccination schedule; CDC Meningococcal Disease Guidance + 2024 vaccination schedule; IDSA Lyme 2021 (Lantos PMID 33417672); WHO TB 2023; SCAI 2022 CS staging (Naidu PMID 35718438); SSC 2026 sepsis bundle — PMID:23824828
  • Cited evidence (PMID 32200645) — PMID:32200645
  • Cited evidence (PMID 33417672) — PMID:33417672
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234