Monitoring

Recommended follow-up is dictated by the clinical course of the individual patient. Patients who exhibit only mild symptoms with prompt resolution of symptoms should be followed closely initially, but monitoring can be quickly spaced out to annual visits unless symptoms recur. However, patient with persistent left ventricular (LV) dysfunction or evidence of progression of myocardial inflammation warrant regular follow-up at least every few months or sooner until the patient is stable clinically.[58][79]

In children, biopsy or cardiac MRI may be necessary if ventricular function, inflammatory biomarkers, or viral activity continue to be abnormal at follow-up.[15]​​

For adults, the American College of Cardiology (ACC) recommends:[56]

  • For low-risk patients with symptomatic (stage C) myocarditis:

    • By 2-4 weeks post discharge: office visit and echocardiogram

    • 6 months post discharge: echocardiogram

  • For medium- to high-risk patients with symptomatic (stage C) or advanced (stage D) myocarditis:

    • By 2-4 weeks post discharge: office visit, biomarkers, ECG, and echocardiogram

    • 6 months post discharge (or 3 months for athletes considering a return to competitive sports): cardiac MRI

Echocardiogram should include assessment of strain if possible. For adults with symptomatic heart failure with reduced ejection fraction, the initial follow-up visit should ideally occur within 1 week, and additional interval visits may be necessary for titration of therapy.[56]

Assessment for return to competitive sports and high-intensity exercise:

  • This is usually done 6 months after diagnosis, but it may be considered after 3 months for some athletes.[56] For adults, the ACC recommends follow-up cardiac MRI, 24-hour monitoring for arrhythmia, and exercise stress testing.[56] Transthoracic echocardiography may be considered instead of cardiac MRI for low-risk patients.[56]

  • Similarly, for children, the American Heart Association recommends normalisation of inflammatory and myocardial injury markers, normalisation of ventricular function and heart failure, 24-hour Holter monitoring, and exercise stress testing before return to competitive sports.[15]

  • If all of these tests are normal and the patient displays no symptoms, return to strenuous exercise and competitive sports is permitted. However, athletes should continue to have periodic reassessment to monitor for recurrence and silent clinical progression, particularly within the first 2 years.[56]

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