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Immune Checkpoint Inhibitor Myocarditis — EECC MCQ

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HardCardiomyopathyImmune Checkpoint Inhibitor MyocarditisEECC

A 42-year-old woman on immune checkpoint inhibitor therapy (nivolumab) for melanoma develops chest pain with troponin elevation (300 ng/L), new LBBB, and LVEF 38%. CMR shows diffuse myocardial oedema. Endomyocardial biopsy shows T-lymphocyte infiltration. What is the specific treatment?

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Correct answer: A — High-dose IV methylprednisolone (1 g daily for 3-5 days), hold the immune checkpoint inhibitor permanently, and escalate to second-line immunosuppression if no response within 24-48 hours

Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but life-threatening complication (mortality 25-50%) characterised by fulminant lymphocytic myocarditis. The 2025 ESC Myocarditis/Pericarditis Guidelines and ESC Cardio-Oncology Guidelines recommend: (1) immediate permanent discontinuation of the ICI; (2) high-dose IV methylprednisolone (1 g/day for 3-5 days as pulse therapy); (3) if no improvement within 24-48 hours, escalate to second-line agents: mycophenolate mofetil, infliximab (anti-TNF-alpha — though caution with concurrent HF), abatacept, or alemtuzumab; (4) standard HF support (GDMT, MCS if cardiogenic shock). ICI myocarditis often presents with concurrent myositis and myasthenia gravis, requiring multidisciplinary assessment.

Reference: ESC (2025): Myocarditis/Pericarditis Guidelines; ESC (2022): Cardio-Oncology Guidelines