Medication Summary
In general, treatment of either acute or chronic myocarditis is aimed at reducing congestion and improving cardiac hemodynamics in heart failure, as well as providing supportive therapy, with the hope of prolonging survival. Treatment of heart failure follows the same treatment regimen regardless of the underlying cause (ie, ACE inhibitors, beta-adrenergic blockers).
Intensive immunosuppressive therapy (eg, corticosteroids, azathioprine, cyclosporine, muromonab-CD3/OKT3) has been shown to have some benefit only in small-scale clinical studies in the treatment of giant cell myocarditis and has not been validated in large clinical trials. At this time, immunosuppressive therapy is not recommended for myocarditis until clear evidence is available from the results of multicenter trials.
Vasodilators
Class Summary
Vasodilators reduce systemic vascular resistance, allowing more forward flow and improving cardiac output. This, in turn, improves myocardial oxygen supply, resulting in dilatation of epicardial and collateral vessels and improving blood supply to the ischemic myocardium.
Nitroglycerin (Minitran, Nitro-Bid, Nitrostat, Nitro-Bid)
Nitroglycerin is the drug of choice for patients who are not hypotensive. It provides excellent and reliable preload reduction, while higher doses provide mild afterload reduction.
The drug has rapid onset and offset (both within minutes), allowing for rapid clinical effects and rapid discontinuation of effects in adverse reactions.
Sodium nitroprusside (Nitropress)
Sodium nitroprusside is considered an afterload reducer. It is a potent direct smooth muscle–relaxing agent that results primarily in afterload reduction but can cause mild preload reduction. The drug produces improved cardiac output, but it can also cause precipitous decreases in blood pressure. Intra-arterial blood pressure monitoring is strongly recommended.
Sodium nitroprusside is an excellent medication in critically ill patients because of rapid onset and offset of action (within 1-2 min). It is excellent for use in cardiogenic pulmonary edema associated with relative hypertension in myocarditis.
ACE inhibitors
Class Summary
Following stabilization of heart failure symptoms, initiation of ACE inhibitors is the standard of care to delay disease progression in heart failure. Beta-adrenergic antagonists should be used only following resolution of congestive symptoms and clinical stabilization of the patient's condition.
Enalapril (Vasotec)
Enalapril is a competitive inhibitor of angiotensin-converting enzymes. It reduces angiotensin II levels, causing a decrease in aldosterone secretion.
Diuretics
Class Summary
Diuretics reduce preload. The initial drop in cardiac output produced by diuresis causes a compensatory increase in peripheral vascular resistance. With continuing diuretic therapy, the extracellular fluid volume and plasma volume return almost to pretreatment levels, and peripheral vascular resistance falls below its pretreatment baseline.
Furosemide (Lasix)
Furosemide is the most commonly used loop diuretic. It increases the excretion of water by interfering with the chloride-binding cotransport system, resulting in inhibition of sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. Furosemide reduces preload through diuresis in 20-60 minutes. It may contribute to more rapid preload reduction through a direct vasoactive mechanism, but this is controversial.
As many as half of all patients with cardiogenic pulmonary edema (CPE) are total-body euvolemic. Furosemide is generally administered to all patients with CPE, but it is probably most useful in patients with total-body fluid overload. The oral form has a slower onset of action and, therefore, is generally not considered appropriate for treating these patients.
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