2025 HFSA Contemporary Issues in Heart Failure - OnDemand-Diagnosis and Treatment of Inflammatory

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Video Summary

Dr. Drew Rosenbaum from the Mayo Clinic presents a comprehensive overview of inflammatory cardiomyopathies, focusing on myocarditis diagnosis and treatment. Myocarditis incidence ranges from 4.4 to 6.1 per 100,000, contributing significantly to sudden cardiac deaths and unexplained dilated cardiomyopathies. Etiologies include viral infections (adenovirus, parvovirus B19), immune checkpoint inhibitor myocarditis, COVID-19 vaccine-related cases, giant cell myocarditis, and eosinophilic syndromes. Diagnosis relies on clinical symptoms, elevated troponins, ECG, echocardiography, cardiac MRI (using updated Lake Louise criteria), and endomyocardial biopsy, recommended in fulminant cases or those with arrhythmias and severe dysfunction. Biopsy interpretation uses Dallas Criteria but faces sensitivity challenges.<br /><br />Myocarditis presents variably from mild symptoms to fulminant heart failure requiring mechanical support or transplantation. Giant cell myocarditis, often autoimmune-related, has a rapid and severe course treated with multidrug immunosuppression. Viral lymphocytic myocarditis generally has a milder course; immunosuppression is reserved for chronic or virus-negative cases. Genetic predispositions, including desmosomal gene variants, are increasingly recognized in recurrent myocarditis.<br /><br />Eosinophilic myocarditis involves toxic eosinophil infiltration and is treated with steroids or IL-5 inhibitors. COVID-19-associated myocarditis appears mostly due to microinfarcts, while COVID vaccine myocarditis is typically mild. Immune checkpoint inhibitor myocarditis ranges in severity and requires prompt immunosuppression, often methylprednisolone, and second-line agents for steroid-resistant cases.<br /><br />Cardiac sarcoidosis is a multisystem granulomatous disease diagnosed via imaging, histology, and PET scans, with treatment evolving to combine corticosteroids and immunosuppressants; novel therapies and clinical trials focus on IL-1 blockade. Differentiating sarcoidosis from mimicking conditions (e.g., genetic cardiomyopathies, amyloidosis) is critical.<br /><br />In summary, a high index of suspicion, imaging, selective biopsy, immunosuppression tailored by etiology, and guideline-directed heart failure management are essential for optimal outcomes in inflammatory cardiomyopathies.

Keywords

inflammatory cardiomyopathies

myocarditis diagnosis

myocarditis treatment

immune checkpoint inhibitor myocarditis

giant cell myocarditis

cardiac sarcoidosis

COVID-19 vaccine myocarditis