2024 ACC Expert Consensus Decision Pathway on Strategies and Criteria for the Diagnosis and Management of Myocarditis: A Report of the American College of Cardiology Solution Set Oversight Committee

Abstract

Section snippets

Solution Set Oversight Committee

Nicole M. Bhave, MD, FACC, ChairNiti R. Aggarwal, MD, FACCKatie Bates, ARNP, DNPJohn P. Erwin iii, MD, FACCMartha Gulati, MD, MS, FACCDharam J. Kumbhani, MD, SM, FACCGurusher S. Panjrath, MBBS, FACCBarbara Wiggins, PharmD, FACCMegan Coylewright, MD, MPH, FACC, Ex Officio

Table of Contents

• Top 10 Key Takeaway Points 3
• 1.Introduction 4
• 2.Assumptions and Proposed Definitions 4
  • 2.1.General Clinical Assumptions 4
  • 2.2.Definitions 5
• 3.Pathway Summary Graphic 5
  • Figure 1. The Evaluation and Management of Clinically Suspected Myocarditis Described as a 5-Step Care Pathway 6
• 4.Description, Rationale, and Implication of Pathway 7
  • 4.1.Diagnosis of Myocarditis 7
    • 4.1.1.Clinical Symptoms 7
      • Figure 2. Three Classic Presentations of Myocarditis 8
  • 4.2.Diagnostic Testing 7
    • 4.2.1.Electrocardiogram 7
    • 4.2.2.Echo and Strain Echocardiography 7
    • 4.2.3.Circulating Cardiac Troponin 7
    • 4.2.4.

Top 10 Key Takeaway Points

• 1.Clinicians need to be aware of the 3 classic presentations of myocarditis: chest pain, heart failure (HF)/shock, and/or symptoms related to arrhythmia (eg, presyncope or syncope). In a young person, the history of an antecedent viral infection, or other risk factors that define stage A at-risk for myocarditis, followed by any of these cardiovascular symptoms should raise the suspicion of this diagnosis.
• 2.High-sensitivity cardiac troponin (hs-cTn) is a common diagnostic test in patients with

General Clinical Assumptions

• 1.The principal focus of this ECDP is on adults with acute myocarditis. For information on myocarditis in the pediatric population, the reader is referred to the “2021 AHA Scientific Statement on Diagnosis and Management of Myocarditis in Children.”¹ This ECDP does not address conditions with chronic inflammatory infiltrates of the myocardium, as this was considered beyond the scope of the paper.
• 2.The writing committee endorses the evidence-based approach to HF and cardiomyopathy diagnosis and

Pathway Summary Graphic

Figure 1 provides a summary graphic outlining the 5-step process for evaluation and management of clinically suspected myocarditis. The initial step is to recognize that a patient's clinical presentation might be consistent with the diagnosis of myocarditis. Given the numerous ways that myocarditis can manifest (Figure 2 and Section 4.1.1), clinicians in a variety of healthcare settings need to be aware of this diagnosis. Examples include primary care physicians; rheumatologists; oncologists;

Description, Rationale, and Implication of Pathway

Based upon a comprehensive literature review and expert opinion, this ECDP aims to inform clinicians regarding the following: 1) the current diagnostic algorithm to follow in the setting of suspected myocarditis; 2) the pivotal role of advanced imaging and EMB in the confirmation of myocarditis; 3) when to refer patients to an advanced HF center and potential therapies for those with advanced myocarditis; 4) a new 4-stage classification of myocarditis, now including those “at-risk” for

President and Staff

Cathleen Biga, MSN, FACC, PresidentCathleen C. Gates, Chief Executive OfficerRichard J. Kovacs, MD, MACC, Chief Medical OfficerBrendan Mullen, Senior Executive Vice PresidentJoseph M. Allen, MA, Team Leader, Science & QualityAmy Dearborn, Team Leader, Decision ScienceAshleigh M. Covington, MA, Team Lead, Decision Science DeliveryAlan Shinkar, MPH, Project Manager, Decision Science DeliveryGrace D. Ronan, Senior Production and Operations Manager, Clinical Policy Publication