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

Cardiogenic shock — fulminant viral / immune myocarditis

cardiologyacuteadult
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11/12 authored

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

Current phase

Frame

Detailed

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

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Myocarditis confirmed and sub-etiology hypothesis stated

Patient inputs (16)

Mandatory rule-out of obstructive CAD (mimics acute MI); typically clean coronaries in myocarditis

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

Younger patients (often <50) over-represented in fulminant viral myocarditis; ICI myocarditis in oncology population; informs prognosis and recovery candidacy

Tachyarrhythmia / heart block common in inflamed myocardium; AV block is a giant-cell myocarditis clue

End-organ damage marker + dose adjustment for supportive medications; gadolinium contrast safety for CMR

Recent URI / GI illness in past 1–4 wks supports viral etiology

Anti-PD1/L1 / anti-CTLA4 within past 12 wks → ICI myocarditis differential; mandates high-dose steroids + abatacept consideration

Markedly elevated; trend correlates with severity; persistent elevation suggests ongoing myocyte injury

Acute HF marker; trend tracks recovery

Eosinophil count is the eosinophilic-myocarditis screen; lymphopenia in some viral cases

Biventricular dysfunction; absence of regional wall motion abnormality crossing single coronary territory; pericardial effusion in 30–50%

New AV block in giant cell myocarditis (~50%); diffuse ST/T-wave changes; PR depression if pericarditis overlap

SCAI 2022 staging baseline; gates vasopressor escalation

SCAI 2022 staging + response to therapy; CardShock prognostication (Harjola EHJ 2015 PMID 26333869)

Parvovirus B19, HHV-6, enterovirus, adenovirus, SARS-CoV-2, EBV — informs viral etiology though does not change supportive-care strategy in adults

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

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

Severity triggers (5)

5 need judgement
  • informationallife_threateninggiant_cell_myocarditis_discovered_on_emb
    Endomyocardial biopsy shows giant cell myocarditis — near-100% mortality without immunosuppression; combination cyclosporine + steroids markedly improves transplant-free survival per Cooper NEJM 1997
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningici_myocarditis_fulminant_with_arrhythmia
    Fulminant ICI myocarditis with sustained VT / VF or high-grade AV block — mortality 25–50%; emergency methylprednisolone 1g IV daily + abatacept; permanent ICI cessation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningventricular_electrical_storm_in_inflamed_myocardium
    Sustained VT/VF or recurrent shocks within 24 h in fulminant myocarditis — high arrhythmia risk in inflamed myocardium; amiodarone + escalate to MCS over higher inotropes; consider catheter ablation if refractory
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmcs_bridge_to_recovery_in_fulminant_viral_myocarditis
    Refractory CS in fulminant viral myocarditis — escalate to MCS (IABP / Impella / VA-ECMO) early; recovery is the rule if patient survives initial period (McCarthy NEJM 2000 PMID 10717012); ELSO 2020 ECMO myocarditis registry — 60–70% survival to discharge
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_grade_av_block_in_acute_myocarditis
    New high-grade AV block (Mobitz II / complete heart block) in acute myocarditis — giant cell myocarditis clue (~50%); emergent endomyocardial biopsy + transvenous pacemaker
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Fulminant myocarditis CS — supportive + cautious inotrope (high arrhythmia risk) + early MCS bridge to recovery + sub-etiology-specific immunosuppression
axis: fulminant_myocarditis_cs_phenotype
Selected axis "Fulminant myocarditis CS — supportive + cautious inotrope (high arrhythmia risk) + early MCS bridge to recovery + sub-etiology-specific immunosuppression" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: fulminant_myocarditis_with_sbp_lt_90, cs_scai_c_or_higher
    SOAP-II PMID 20200382 — NE first-line in CS
    rxcui 7512
  • dobutamine
    second line
    inotrope_beta1
    2.5 µg/kg/min CAUTIOUS titration; AVOID in ventricular electrical storm • IV • continuous
    triggers: low_cardiac_output_despite_NE, no_active_VT_or_VF
    DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in inflamed myocardium given high arrhythmia risk; escalate to MCS rather than higher inotrope doses
    rxcui 3616
  • methylprednisolone
    first line
    corticosteroid_systemic
    1000 mg IV daily × 3–5 days, then 1 mg/kg/d taper • IV • daily
    triggers: ici_myocarditis_confirmed_or_strongly_suspected, eosinophilic_myocarditis, giant_cell_myocarditis_emb_confirmed
    AHA 2024 ICI cardiotoxicity statement — high-dose pulse steroids for ICI myocarditis; ESC 2013 myocarditis position paper for eosinophilic / giant cell
    rxcui 6902
  • cyclosporine
    first line
    calcineurin_inhibitor
    3–5 mg/kg/d divided BID; trough target 200–300 ng/mL • PO/IV • BID
    triggers: giant_cell_myocarditis_emb_confirmed
    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
    rxcui 3008
  • abatacept
    add on
    ctla4_ig_fusion_protein
    500–1000 mg IV q2 wks × multiple doses per refractory ICI myocarditis protocol • IV • q2 weeks
    triggers: ici_myocarditis_steroid_refractory, fulminant_ici_myocarditis_with_arrhythmia
    Salem JACC 2018 + AHA 2024 ICI cardiotoxicity statement — abatacept for steroid-refractory ICI myocarditis; CTLA4-Ig blunts T-cell activation
    rxcui 614391
  • infliximab
    add on
    tnf_alpha_inhibitor
    5 mg/kg IV • IV • single dose, may repeat
    triggers: ici_myocarditis_steroid_refractory_with_preserved_ef
    AHA 2024 ICI cardiotoxicity statement — alternative to abatacept; CONTRAINDICATED if EF <35 (TNF inhibitor worsens HF per ATTACH NEJM 2003)
    rxcui 191831
  • phenylephrine
    second line
    vasopressor_pure_alpha
    40–360 µg/min IV • IV • continuous
    triggers: arrhythmia_risk_with_NE, need_pure_alpha_pressor
    Pure α-pressor; alternative when β-stimulation aggravates arrhythmias in inflamed myocardium
    rxcui 8163
  • amiodarone
    rescue
    class_iii_antiarrhythmic
    150 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min • IV • continuous
    triggers: ventricular_electrical_storm_in_myocarditis, sustained_vt_or_vf
    AHA 2020 ACLS Class IIb for refractory VT/VF; high arrhythmia risk in inflamed myocardium
    rxcui 703
  • metformin
    contraindication substitute
    placeholder_avoid
    AVOID NSAIDs • n/a • n/a
    triggers: fulminant_myocarditis
    AVOID NSAIDs — animal models worsen myocarditis (ESC 2013 position paper); listed as a contraindication marker rather than a drug
    rxcui 6809

outpatient playbook — drug actions (3)

  1. 1. continue or up-titrate GDMT 4-pillar if persistent EF<40
    lisinopril or sac/val + carvedilol + MRA + SGLT2i • PO • daily/BID
    trigger: Persistent EF<40
    AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499)
  2. 2. continue cyclosporine + low-dose steroids for giant cell
    rxcui 3008
    cyclosporine trough 100–200 ng/mL chronic; prednisone 5–10 mg/d • PO • daily
    trigger: Giant cell myocarditis
    Cooper NEJM 1997 — chronic immunosuppression maintains transplant-free survival
  3. 3. AVOID ICI rechallenge after fulminant ICI myocarditis
    oncology coordination • n/a • n/a
    trigger: History of fulminant ICI myocarditis
    AHA 2024 ICI cardiotoxicity statement — rechallenge generally CONTRAINDICATED after fulminant

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recent viral prodrome (URI / GI illness in past 1–4 wks) followed by acute heart failure + cardiogenic shock physiology — fulminant myocarditis with CS; 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.

Objective

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

Assessment

**Cardiogenic shock — fulminant viral / immune myocarditis** (cardio.cardiogenic-shock.viral-myocarditis.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Fulminant myocarditis CS — supportive + cautious inotrope (high arrhythmia risk) + early MCS bridge to recovery + sub-etiology-specific immunosuppression**.
1. 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
2. dobutamine 2.5 µg/kg/min CAUTIOUS titration; AVOID in ventricular electrical storm IV continuous (inotrope_beta1, second line) — DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in inflamed myocardium given high arrhythmia risk; escalate to MCS rather than higher inotrope doses
3. methylprednisolone 1000 mg IV daily × 3–5 days, then 1 mg/kg/d taper IV daily (corticosteroid_systemic, first line) — AHA 2024 ICI cardiotoxicity statement — high-dose pulse steroids for ICI myocarditis; ESC 2013 myocarditis position paper for eosinophilic / giant cell
4. cyclosporine 3–5 mg/kg/d divided BID; trough target 200–300 ng/mL PO/IV BID (calcineurin_inhibitor, first line) — 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
5. abatacept 500–1000 mg IV q2 wks × multiple doses per refractory ICI myocarditis protocol IV q2 weeks (ctla4_ig_fusion_protein, add on) — Salem JACC 2018 + AHA 2024 ICI cardiotoxicity statement — abatacept for steroid-refractory ICI myocarditis; CTLA4-Ig blunts T-cell activation
6. infliximab 5 mg/kg IV IV single dose, may repeat (tnf_alpha_inhibitor, add on) — AHA 2024 ICI cardiotoxicity statement — alternative to abatacept; CONTRAINDICATED if EF <35 (TNF inhibitor worsens HF per ATTACH NEJM 2003)
7. phenylephrine 40–360 µg/min IV IV continuous (vasopressor_pure_alpha, second line) — Pure α-pressor; alternative when β-stimulation aggravates arrhythmias in inflamed myocardium
8. amiodarone 150 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min IV continuous (class_iii_antiarrhythmic, rescue) — AHA 2020 ACLS Class IIb for refractory VT/VF; high arrhythmia risk in inflamed myocardium
9. metformin AVOID NSAIDs n/a n/a (placeholder_avoid, contraindication substitute) — AVOID NSAIDs — animal models worsen myocarditis (ESC 2013 position paper); listed as a contraindication marker rather than a drug

Setting playbook (outpatient) — 4–8 wk recovery echo + CMR — confirm LV recovery (typical for fulminant viral; variable for giant cell / ICI); long-term GDMT if persistent HFrEF; EP follow-up for ICD eligibility (waiting period given recovery potential per AHA 2017 VA/SCD guideline); ongoing immunosuppression for giant cell; oncology coordination for ICI patients (rechallenge contraindicated after fulminant)
10. continue or up-titrate GDMT 4-pillar if persistent EF<40 lisinopril or sac/val + carvedilol + MRA + SGLT2i PO daily/BID — Persistent EF<40 (AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499))
11. continue cyclosporine + low-dose steroids for giant cell cyclosporine trough 100–200 ng/mL chronic; prednisone 5–10 mg/d PO daily — Giant cell myocarditis (Cooper NEJM 1997 — chronic immunosuppression maintains transplant-free survival)
12. AVOID ICI rechallenge after fulminant ICI myocarditis oncology coordination n/a n/a — History of fulminant ICI myocarditis (AHA 2024 ICI cardiotoxicity statement — rechallenge generally CONTRAINDICATED after fulminant)

Non-pharmacologic actions:
- No competitive sports × 3–6 mo per AHA 2015 / ESC 2020 sports cardiology
- Cardiac rehab if persistent LV dysfunction
- EP referral for ICD eligibility per AHA 2017 VA/SCD guideline
- Transplant evaluation if persistent severe LV dysfunction beyond 6 mo

AVOID / contraindication checks:
- Nsaids_AVOID_in_myocarditis (animal models worsen; ESC 2013 myocarditis position paper)
- Infliximab_AVOID_in_ef_lt_35 (worsens HF per ATTACH NEJM 2003 PMID 12668597)
- High_dose_dobutamine_minimize_in_inflamed_myocardium (arrhythmia risk; escalate to MCS instead)
- Digoxin_AVOID_in_acute_myocarditis (toxicity threshold lowered in inflamed myocardium per ESC 2013)
- Gadolinium_caution_if_egfr_lt_30 (NSF risk; group II macrocyclic agents safer)
- Cyclosporine_renal_adjust (calcineurin nephrotoxicity; trough monitoring)

Monitoring

Regimen monitoring:
- arterial line continuous BP (ACC/AHA 2022 Class I)
- central venous access (ACC/AHA 2022)
- lactate q1-2h (CardShock, Harjola EHJ 2015)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- serial echo q24h for recovery trajectory (McCarthy NEJM 2000 — fulminant viral has high recovery rate)
- continuous telemetry for arrhythmia (high VT/VF and AV block risk in inflamed myocardium)
- daily troponin and bnp (trend tracks recovery)
- daily cbc with diff if immunosuppression (cyclosporine, steroids — opportunistic infection screen)
- cyclosporine trough 200-300 ng mL (giant cell myocarditis regimen)

Setting (outpatient) monitoring:
- Echo at 6 mo and 12 mo
- CMR at 6 mo if persistent LGE for arrhythmic risk surveillance
- Cyclosporine trough monthly if giant cell

Follow-up plan: 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
- Close-out criterion: Recovery echo, CMR, GDMT, ICD eligibility timeline booked

Monitoring phase: 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

Disposition

Current setting: outpatient — 4–8 wk recovery echo + CMR — confirm LV recovery (typical for fulminant viral; variable for giant cell / ICI); long-term GDMT if persistent HFrEF; EP follow-up for ICD eligibility (waiting period given recovery potential per AHA 2017 VA/SCD guideline); ongoing immunosuppression for giant cell; oncology coordination for ICI patients (rechallenge contraindicated after fulminant)

Disposition criteria:
- Complete recovery (EF ≥55 + symptom-free + CMR resolved) → routine surveillance only
- Persistent HFrEF → long-term cross-link to cardio.hfref.core.v1 / cardio.hf.core.v1

Escalation triggers (move to higher acuity):
- Sustained VT / syncope → EP urgent consult; consider catheter ablation; ICD
- Persistent severe LV dysfunction → transplant evaluation
- Recurrent myocarditis → repeat workup; reconsider underlying etiology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Endomyocardial biopsy shows giant cell myocarditis — near-100% mortality without immunosuppression; combination cyclosporine + steroids markedly improves transplant-free survival per Cooper NEJM 1997
- [LIFE_THREATENING] Fulminant ICI myocarditis with sustained VT / VF or high-grade AV block — mortality 25–50%; emergency methylprednisolone 1g IV daily + abatacept; permanent ICI cessation
- [LIFE_THREATENING] Sustained VT/VF or recurrent shocks within 24 h in fulminant myocarditis — high arrhythmia risk in inflamed myocardium; amiodarone + escalate to MCS over higher inotropes; consider catheter ablation if refractory

Citations

- 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) [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 10717012) [PMID:10717012](https://pubmed.ncbi.nlm.nih.gov/10717012/)
- Cited evidence (PMID 30025572) [PMID:30025572](https://pubmed.ncbi.nlm.nih.gov/30025572/)
- Cited evidence (PMID 17998456) [PMID:17998456](https://pubmed.ncbi.nlm.nih.gov/17998456/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:23824828
  • Cited evidence (PMID 32200645) — PMID:32200645
  • Cited evidence (PMID 10717012) — PMID:10717012
  • Cited evidence (PMID 30025572) — PMID:30025572
  • Cited evidence (PMID 17998456) — PMID:17998456