Myocarditis Staging and Management
Stage | Stage A | Stage B | Stage C | Stage D |
|---|---|---|---|---|
Description | At risk | Asymptomatic | Symptomatic | Severe |
Symptoms | No | No | Yes | Yes |
Diagnostic testing (biopsy, CMRI, troponin) | Normal | Biopsy or CMRI meets diagnostic criteria OR abnormal cardiac troponin with additional supportive evidence | Biopsy or CMRI meets diagnostic criteria OR abnormal cardiac troponin with additional supportive evidence | Biopsy or CMRI meets diagnostic criteria OR abnormal cardiac troponin with additional supportive evidence |
Additional testing (if not already done) | None | ECG | ECG; Consider biopsy | ECG; Perform biopsy |
Management | Remove offending agent when appropriate Risk counseling | Remove offending agent when appropriate Treat cause | Consider hospitalization and/or referral to heart failure center Guideline-directed medical heart failure therapy Immunosuppression or other etiology-based treatment | Hospitalize in intensive care unit; refer to heart failure center Hemodynamic stabilization, including mechanical support as needed Arrhythmia treatment Guideline-directed medical heart failure therapy Long-term mechanical support or transplantation if needed |
Follow-up | Monitor for progression | Monitor for symptoms Repeat CMRI and echocardiogram Consider genetic counseling/testing | Serial troponin, CMRI, and echocardiography Consider genetic counseling/testing | Serial troponin, CMRI, and echocardiography Consider genetic counseling/testing |
Activity | N/A | Consider clinical scenario | Restrict strenuous activity for 3–6 months; return to activity per guidelines | Restrict strenuous activity for 3–6 months; return to activity per guidelines |
Writing Committee, Drazner MH, Bozkurt B, et al. 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. J Am Coll Cardiol. 2025;85(4):391-431. doi:10.1016/j.jacc.2024.10.080 | ||||
CMRI = cardiac magnetic resonance imaging. | ||||