Autoimmune Myocarditis

What is Autoimmune Myocarditis?

Autoimmune myocarditis is inflammation of the heart muscle (the myocardium) in which an abnormal immune response against the heart plays a central role. It can occur on its own, alongside a systemic autoimmune disease such as lupus, or after a trigger such as a viral infection or a cancer immunotherapy drug.^{[1, 2]} It is a condition that needs medical care, and some forms are emergencies.

Common symptoms

Symptoms range from mild to life-threatening and often overlap with other heart problems. Chest pain is the most common sign in adults, and some people also have shortness of breath, fainting, palpitations or fatigue.^{[2, 3]} Severe cases can bring heart failure, dangerous heart rhythms, cardiogenic shock or sudden death.^[4]

Causes and risk factors

Viral infections are the most common cause of acute myocarditis overall. Other causes include systemic autoimmune disorders such as lupus, drugs such as immune checkpoint inhibitors, and vaccines, including smallpox and mRNA COVID-19 vaccines.^[2] Researchers have found that immune T cells reacting to a heart muscle protein can drive autoimmune forms, but the exact targets and pathways are still not fully understood.^[1]

How it is diagnosed and treated conventionally

Diagnosis is suggested by symptoms, raised troponin levels, ECG changes and heart ultrasound findings. Cardiac MRI or a heart tissue biopsy is needed to confirm it.^[2]

Treatment depends on how severe the illness is and what caused it. Supportive treatment for heart failure and rhythm problems is the foundation, and corticosteroids or other immune-suppressing drugs are used for particular forms, such as those linked to systemic autoimmune disease. This practice rests mostly on limited evidence, and trials are still needed.^{[2, 4]} Many people recover fully, but a minority develop long-term heart muscle weakness.^[4]

Why Autoimmune Myocarditis calls for a whole-person approach

Several factors act together in autoimmune myocarditis: the immune response, the trigger or underlying disease, the strain on the heart, and how the person is coping. Medical teams focus on the first three, and symptoms such as stress, poor sleep and fatigue are often left to the patient.

Supportive care can reasonably address those everyday effects. It cannot treat the inflammation in the heart muscle.

Immune activity

Immune dysregulation is central. Even in myocarditis that starts with a virus, an overactive immune response contributes to the damage.^[1] This is why some patients take immune-suppressing medicines, and why any herb said to "stimulate" or "modulate" immunity needs your cardiologist's review.

The underlying disease or trigger

Myocarditis is more frequent in people with systemic autoimmune disorders such as lupus and polymyositis.^[1] Treating the underlying disease or removing the trigger is part of medical care.^[2]

Heart rhythm and heart failure symptoms

Myocarditis can cause palpitations, arrhythmias and heart failure.^[4] These need monitoring by a cardiologist. Questions about activity, including sports, should also go to your cardiology team.

Stress, sleep and fatigue

A systematic review of 24 trials in people with heart failure found small-to-moderate benefits from mind-body approaches such as tai chi, yoga and relaxation on quality of life, exercise capacity, anxiety, depression and fatigue. It reported that most studies were small.^[5] This evidence is for heart failure, not for myocarditis, but it suggests that stress and fatigue can be addressed alongside heart treatment.

Acupuncture as supportive care in Autoimmune Myocarditis

What the research shows

A PubMed search found no clinical trials of acupuncture for autoimmune myocarditis, and none for viral myocarditis. Nothing is known about whether acupuncture affects the course of the disease.

Some studies look at related heart problems. A systematic review of 7 trials of acupuncture in heart failure, most with considerable methodological flaws, found reports of better exercise capacity and quality of life but called the evidence inconclusive.^[6] An overview of 10 systematic reviews of acupuncture for arrhythmias found improvements in several rhythm measures, but rated the methodological quality as very low and the evidence as mostly low or very low quality.^[7] A separate review of 9 trials noted that only one had a low risk of bias and that no robust conclusion could be reached.^[8] These results are for other heart conditions and cannot be assumed to apply to myocarditis.

How acupuncture may work

For myocarditis, there is no mechanism research in people. In heart failure studies, researchers have reported changes in heart rate variability, a measure of the balance between the nervous system's two arms, after acupuncture.^[6] This is a proposed explanation from a different condition, not an established mechanism.

What treatment involves

We offer acupuncture only after your condition is under medical management and your treating team knows you are receiving complementary care. Sessions use fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, with reassessment after a short course of visits.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[9] Tell the practitioner first if you take blood thinners, have a bleeding disorder, are pregnant, or have a pacemaker or implanted defibrillator, since electroacupuncture may not be suitable.

Ayurvedic medicine as supportive care in Autoimmune Myocarditis

The Ayurvedic view

Ayurveda has no classical diagnosis that matches autoimmune myocarditis. Heart conditions were traditionally grouped under disorders of the heart (hridroga), described in terms of imbalances of the doshas and of digestion and metabolism. These are traditional frameworks, not biomedical diagnoses, and they do not guide treatment of myocarditis.

Therapies that may be used

Supportive Ayurvedic care is limited to gentle measures chosen for the individual:

• Regular meals, sleep and daily routine, and stress-reducing practices such as breathing exercises, as long as your cardiologist agrees
• Gentle oil massage for relaxation
• Herbs, only after review of your medicines by a qualified practitioner and your physician

Panchakarma procedures are not appropriate during acute illness, in frailty, in pregnancy, or while heart function is unstable. They are not a part of care for active myocarditis.

What the research shows

No clinical trials of Ayurvedic treatment for myocarditis were found. Laboratory work exists: curcumin, from turmeric, reduced heart inflammation and improved heart function in rats with experimental autoimmune myocarditis. This animal finding has not been tested in patients.^[10]

Arjuna (Terminalia arjuna) is a traditional heart herb. A very small crossover trial of 12 patients with severe heart failure, with two weeks on each treatment, reported symptom and heart function improvements compared with placebo.^[11] A systematic review of Terminalia arjuna in stable angina, based on poorly designed studies, found the evidence insufficient to support or reject benefit.^[12] Neither addresses myocarditis.

Herbal medicine as supportive care in Autoimmune Myocarditis

Herbs and formulas that have been studied

Almost all clinical research is on viral myocarditis in China. It covers astragalus (Astragalus membranaceus, huangqi), often given as an injection, and Shengmai San, a formula traditionally used to support qi and yin.^{[13, 14]} Astragalus injection is a hospital-type product, and the studies do not tell us how oral herbs would compare.

What the research shows

The evidence is limited and low in quality. An overview of 6 systematic reviews covering 67 trials in adults with viral myocarditis found that Chinese herbal medicine combined with Western medicine had positive effects on rhythm, ejection fraction, heart muscle enzymes and symptoms. The authors rated study quality as modest and called for larger, better trials.^[15]

A meta-analysis of 44 trials of Shengmai San reported better recovery from palpitations, dyspnea and chest pain, and lower troponin, but described the overall quality as low and noted no placebo-controlled trials.^[14] A meta-analysis of 19 trials, all in China, reported lower inflammatory markers with astragalus injection and cautioned about large differences between studies.^[13]

These trials studied viral myocarditis, not autoimmune myocarditis specifically, and the benefits cannot be assumed to carry over.

Safety and herb-drug interactions

Herbs can interact with heart and immune-suppressing medicines. Reviews describe bleeding when danshen, ginkgo or ginger was combined with warfarin, and raised digoxin levels with Siberian ginseng.^{[16, 17]} St. John's wort lowered blood levels of ciclosporin and tacrolimus, with organ rejection reported in some cases.^[16] Tell us if you take steroids, azathioprine, methotrexate, blood thinners, beta-blockers, diuretics, ACE inhibitors or digoxin. Herbal products that claim to affect immunity should be avoided unless your cardiologist agrees.

Herbal and dietary supplements account for about 20% of drug-induced liver injury cases in the United States, and the product causing the harm is often hard to identify.^[18] In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[19] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine would describe some people with myocarditis as having deficiency of qi and yin, and Shengmai San is traditionally used to supplement these. Researchers study such formulas by measuring inflammatory signals, heart enzymes, rhythm and heart function.^{[13, 14]}

Ayurveda's concepts of weak digestion and metabolism or aggravated doshas have no tested biological counterpart in this condition. Neither framework replaces the immunology and cardiology that guide treatment.^[1]

How this care fits with your medical care

Supportive care is complementary and begins only after myocarditis is under medical management. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Do not stop or change any prescribed medicine, and follow your cardiologist's advice on activity.

We do not diagnose or manage the disease. Please bring your diagnosis, recent test and imaging reports, and a full list of medicines and supplements.

When to seek urgent medical care

Myocarditis can worsen quickly, and some of its complications are emergencies.^[4]

• Chest pain or pressure, especially new or worsening
• Shortness of breath at rest or when lying flat
• Fainting or near-fainting
• A racing, pounding or very irregular heartbeat
• Rapid swelling of the legs, ankles or abdomen, or sudden weight gain
• Fever with chest symptoms after a viral illness

If any of these occur, call 911 or go to the nearest emergency department.