Myocarditis — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 26-year-old man presents with chest pain 2 weeks after a respiratory infection. He is haemodynamically stable and not breathless. Troponin is raised, the ECG shows ST-segment elevation, and coronary CT angiography shows no obstructive coronary disease. Echocardiography shows a new LVEF of 45%.^[1] CMR the next day shows a regional increase in T2 relaxation time and mid-wall LGE in two segments.^[5][1]

1. Under ESC 2025 Table 4, is this definite, possible or unlikely myocarditis, and why? (2)^[1]
2. Name the two groups of updated Lake Louise criteria, with one example of each. (2)^[1][5]
3. Is this complicated myocarditis under ESC 2025 Table 3, and what is his ESC 2025 Table 7 imaging risk category? (2)^[1]
4. Where should he be managed under ESC 2025, with class and level? (1)^[1]
5. Give the ESC 2025 Recommendation Table 9 rows that apply to his LV systolic dysfunction and to arrhythmia prevention, with class and level. (2)^[1]
6. Would ESC 2025 recommend routine viral serology? (1)^[1]

Model answers — SAQ 1

1. Definite myocarditis (1 mark).^[1] ESC 2025 Table 4: a clinical presentation and a CMR-proven result, which means 2 out of 2 updated Lake Louise criteria fulfilled (1 mark).^[1]
2. T2-based criteria, for example a global or regional increase of myocardial T2 relaxation time or increased signal intensity in T2-weighted images (1 mark).^[5][1] T1-based criteria, for example increased myocardial T1, LGE or ECV (1 mark).^[5][1]
3. Yes: ESC 2025 Table 3 defines complicated myocarditis as acute myocarditis and ≥1 of LVEF <50% on echocardiogram, sustained ventricular arrhythmias, advanced heart block, heart failure or cardiogenic shock; his LVEF is 45% (1 mark).^[1] Intermediate risk on imaging: newly mildly reduced LVEF (41%–49%) and/or WMA in ESC 2025 Table 7 (1 mark).^[1]
4. Hospital admission is recommended for patients with moderate- to high-risk myocarditis for monitoring and treatment (ESC 2025, Class I, Level C) (1 mark).^[1]
5. Adherence to the ESC HF guidelines is recommended in myocarditis with LV systolic dysfunction and/or HF to reduce symptoms and improve LV function (ESC 2025, Class I, Level C) (1 mark; also accept the row that HF therapy should be considered in myocarditis and LV systolic dysfunction for at least 6 months upon complete LV functional recovery to stabilize LV function, ESC 2025, Class IIa, Level C).^[1] β-Blockers, continued for at least 6 months, should be considered in acute myocarditis, especially with troponin elevation, to control symptoms and prevent arrhythmias (ESC 2025, Class IIa, Level C) (1 mark).^[1]
6. No: routine serology is not recommended for the evaluation of viral aetiology except for hepatitis C, HIV and Lyme disease (ESC 2025, Class III, Level C) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 70-year-old woman receiving combination immune checkpoint inhibitor therapy for lung cancer develops muscle weakness and new right bundle branch block 3 weeks after her first dose. Troponin is raised.^[1] She is haemodynamically stable.

1. What is the main risk factor for ICI-induced myocarditis, and how common is it in treated patients, per ESC 2025? (2)^[1]
2. Give the ESC 2025 row on how quickly she should be triaged, with class and level. (1)^[1]
3. Coronary angiography shows moderate coronary disease. Does that end the myocarditis work-up? (1)^[1]
4. ICI-associated myocarditis is confirmed. Give the ESC 2025 Class I treatment row. (2)^[1]
5. After 48 hours of steroids troponin keeps rising. What do ESC 2025 Recommendation Table 18 and Table 12 say? (2)^[1]
6. Her oncologist asks about restarting immunotherapy. What does ESC 2025 advise? (2)^[1]

Model answers — SAQ 2

1. Combination therapy with two types of ICI, such as an anti-CTLA-4 combined with an anti-PD-1 (1 mark).^[1] Approximately 1% of treated patients, within the first weeks after starting therapy (1 mark).^[1]
2. Diagnostic triage within 24 h is recommended in suspected ICI-induced myocarditis to initiate treatment rapidly (ESC 2025, Class I, Level C) (1 mark).^[1]
3. No: ESC 2025 says detection of coexisting CAD in older patients should not stop further work-up for myocarditis, and CAD may coexist with ICI-induced myocarditis (1 mark).^[1]
4. Immediate disruption of the ICI (1 mark) and administration of high-dosage corticosteroids, to stop the inflammatory reaction and stabilize the patient (ESC 2025, Class I, Level C) (1 mark).^[1]
5. Second-line immunosuppression should be considered in steroid-refractory ICI-associated myocarditis (ESC 2025, Class IIa, Level C) (1 mark).^[1] ESC 2025 Table 12 second line, if no response in 24–48 h: mycophenolate mofetil, ATG, abatacept or alemtuzumab (1 mark).^[1]
6. Rechallenge has to be considered after a multidisciplinary team discussion (1 mark), weighing the severity of the myocarditis, cancer prognosis, oncology treatment options and patient preference (1 mark).^[1]