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Steroids and myocarditis

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Two reviewers independently screened the title and abstract, selected the studies and assessed the quality of studies. Characteristics of subjects, design of trials, course of arrangement and analysis were abstracted and rated. Quality assessment of randomized controlled trials RCTs were based on the 7-point Modified Jadad Score, including 7 items on randomization, blinding, allocation concealment, withdrawals and dropouts.

Studies were of high quality if they got 4 or more points. The quality of enrolled retrospective cohort studies was evaluated by the 9-star Newcastle-Ottawa Quality Assessment Scale, including 8 items on patient selection, comparability and outcome. Studies were interpreted as high-quality studies if they got 5 or more stars. Divergence was resolved by discussion, or by recourse to a third reviewer.

Publication bias was assessed by Funnel plot. We used the Review Manager 5. We tested the heterogeneity of study data by forest plot, the Q -test as well as I 2 statistics. We also compared the two medicines by weighted independent t -test. A total of 4, studies were retrieved using the retrieval methods mentioned above.

Finally, there were eight studies 11 — 18 being adopted based on exclusion and inclusion criteria Figure 1 , consisting of two randomized controlled trials and six retrospective studies. All studies were published in English. Table 1 shows the general background of eight studies and the list of characteristics of the subjects such as age. In total, pediatric patients with myocarditis or DCM were included, consisting of patients in the experimental group and patients in the control group.

The range of mean age of the research subjects was 0— Two of the eight studies regarded only left ventricular ejection fraction LVEF as the endpoint of follow-up, while four of the studies used only death or heart transplantation to indicate pharmaceutical effect. The remaining studies used both LVEF and death or heart transplantation to reflect the therapeutic efficacy. In studies mentioning the administration time, the mean time for corticosteroids administration varied from 1 to 8 months, while the range of mean time for IVIG administration was from 2 to 5 days.

Follow-up duration lasted from 1 month to 5 years. The results of quality assessment showed that six of the eight studies were high-quality studies Table 1. Funnel plot analysis indicates significant publication bias for the increase in LVEF and death or heart transplantation incidence Figure 2. The number of articles available is likely a major contributing factor, which also limits our further test for funnel plot asymmetry.

Figure 2. Funnel plot of included studies. B Funnel plot of six clinical trials using death or heart transplantation as the endpoint. LVEF of children with myocarditis or dilated cardiomyopathy after intervention was reported in four trials. A total of subjects were included, 81 in the treatment group and 76 in the control group. Figure 3. Forest plot of four studies using LVEF as the endpoint. Comparison of drugs and conventional therapy on the outcome of left ventricular ejection fraction in pediatric myocarditis, excluding nonevent trials.

A random effects model was used. CI, confidence interval; SD, standard deviation. Six studies assigned death or heart transplantation as the endpoint of investigation, in which investigation of 49 patients ended with death or heart transplantation. This consisted of 13 patients in the medication group and 36 patients in the control group.

Figure 4. Forest plot of six studies using death or heart transplantation as the endpoint. Drugs vs. Fixed effect model for combined effect size was used. Table 2. Comparisons of percentages of death and heart transplantation in children with myocarditis treated by corticosteroids and intravenous immunoglobulin. The results of our meta-analysis show that there is no significant difference in increased LVEF from a 1 month- to 8 month- follow-up and decreased death or heart transplantation incidence at the end of follow-up between the use of corticosteroids and that of conventional therapy in children with myocarditis or dilated cardiomyopathy.

Compared to conventional therapy, additional IVIG treatment may be beneficial for the improvement of LVEF at follow-up over the course from 6 months to 1 year and for a decrease in death or heart transplantation rate at the end of follow-up. Potential etiologies of myocarditis include infections, physical agents, toxins, medications, autoantigens and so on Viral and post-viral myocarditis are major causes of dilated cardiomyopathy 1.

The spectrum of viruses varies from enteroviruses especially coxsackievirus , human herpesvirus 6, adenovirus, Epstein-Barr virus to parvovirus B19, hepatitis C and cytomegalovirus both in children and adults. Trypanosoma cruzi is a common cause of myocarditis in Central and South America Our meta-analysis did not include this type of myocarditis because of its distinctive epidemiology, pathogenesis, treatment and management Lymphocytic myocarditis is the most common viral myocarditis 9.

Manifestations of myocarditis differ in children. Signs and symptoms can be sub-clinical, while patients sometimes experience chest pains similar to pericarditis or myocardial infarction, or even undergo sudden cardiac death from ventricular fibrillation. Moreover, symptoms of heart failure might occur when the disease develops into DCM, leading to death or heart transplantation. The exact mechanisms for the injury during viral myocarditis have been studied for decades.

Research on rodent models and isolated cell systems have shown three phases in the pathophysiology. During phase 1, viruses enter myocytes and macrophages through specific receptors and coreceptors and activate the innate immune response. Phase 2 involves viral replication and an acquired immune response. Protein products of viral genomes can also cause damage to myocardium.

Phase 3 is either recovery or DCM. Cellular necrosis triggers the host's immune system and causes further degradation. Molecular mimicry possibly plays an important role in this autoimmune response. On most occasions, the status improves as viral titers decrease, whereas in some cases the disease evolves to chronic dilated cardiomyopathy and become irreversible.

It is not clear whether viral persistence or reactivation of latent virus is involved in the chronic phase and eventual onset of DCM. Some viruses, such as parvovirus B19, can also cause myocarditis indirectly by infecting cardiac endothelial cells 1 , 3 , 9 , The outcome, prognosis, and efficacy of treatment of myocarditis are closely related to etiology, clinical manifestations and the phase of disease.

Conventional therapy includes optimal management of arrhythmia and of heart failure. In patients whose conditions deteriorate, mechanical circulatory support is required, such as extracorporeal membrane oxygenation ECMO or ventricular assist devices, as a bridge to recovery or heart transplantation. As immunosuppressants, corticosteroids could be effective in the second phase of myocarditis with the three-phase pathological course.

However, our meta-analysis shows that there is no significant difference in LVEF and death or heart transplantation ratio in children between the corticosteroids group and the conventional treatment group. Corticosteroids use should depend on a prompt diagnosis and a clear assessment of the stage of myocarditis. In the three studies included, however, corticosteroids use varied among different stages of the patients, which likely resulted in no significant differences.

In addition, using corticosteroids in acute myocarditis may exacerbate the situation through immunosuppression during the acute viremic phase 11 — Although several previous randomized controlled trials 24 , 25 and meta-analyses 26 have proven the efficacy of corticosteroids, these findings were based primarily on adults. The conclusion may not be conveniently extrapolated to the pediatric population as a result of different etiologies and different physical conditions.

On the other hand, our findings reveal that IVIG may have a therapeutic effect on pediatric myocarditis. Studies have shown that immunoglobulin G and polyvalent intravenous immunoglobulins IgG, IgA, and IgM exert proinflammatory effects, including the activation of immune cells, the complement system, and the opsonization of infective agents. They also have anti-inflammatory effects which comprise the neutralization of bacterial and other toxins, degradation products and an excess of complement factors and cytokines, which help to balance the proinflammatory process 27 — IVIG can modulate the inflammatory and immune response without major side effects.

Thus, if ongoing infection, a post-infectious inflammatory reaction, or a non-infectious process play a role, IVIG can be efficacious However, additional and larger-scale randomized controlled trials on children are necessary for further investigation of IVIG use. Theoretically, immunosuppressive therapy could lead to side-effects, including infectious diseases, hypertension, edema, an increase in body weight and so on While IVIG therapy was principally associated with infusion-related side effects, all incidences were reported to be mild We also took adverse drug reaction into account, although it was not comprehensively mentioned in the retrieved articles and reflects a limitation of these studies.

Considering the validity of medication targeting different periods of pathologic process, combination therapy may be a more effective option. However, far less research 13 , 31 regarding steroid agents combined with IVIG for treating pediatric myocarditis was retrieved. Several studies indicated that combination treatment groups conferred advantages over the control group, while others showed no significant difference in therapeutic effects between the two groups.

Therefore, performing more trials to study the efficacy and safety of combined treatment is necessary. Most previously reported meta-analyses about the treatment for myocarditis 26 , 32 targeted adults as research subjects. Moreover, most of these mentioned only IVIG or steroid agents, rather than both. On account of the significant morbidity and mortality rates of pediatric myocarditis, it is of great importance to further investigate more effective therapies. Additionally, our meta-analysis compared the efficacy of corticosteroids and IVIG, which might be taken as a reference for further researches.

There were some limitations to the present study. The inverted funnel plot demonstrated an existence of publication bias. It is difficult to unify the diagnostic criteria and most studies lacked a clear assessment of the stage of myocarditis. Several different standards for judging the efficacy of medication were not all-inclusive in involved studies so that we could not estimate it completely. In addition, in biopsy-proven virus-negative patients whose condition deteriorates despite optimal conventional management, immunosuppressive therapy should be considered after ruling out the possible contraindications.

Further randomized controlled trials with a larger sample size are required to unambiguously delineate the clinical effect of corticosteroids and IVIG in the treatment of myocarditis in children. The datasets generated for this study are available on request to the corresponding author.

YLi and YY screened the title and abstract, selected the studies, assessed the quality of evidence, extracted the data, and performed the analysis. SC and YLia supervised study selection and data analysis. YLi and YY drafted the initial manuscript. All authors contributed to manuscript revision and read and approved the submitted version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Cooper LT Jr. N Engl J Med. Thus, some clinicians initiate steroids with or without IVIG when patients clinically decompensate despite advanced cardiopulmonary support in an effort to treat cryptogenic primary immune processes. Although IVIG treatment is controversial and its use cannot be routinely recommended, it is possible that in select cases when myocarditis has been proven and there is no response to intensive supportive measures, IVIG may be considered.

This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles.

Journal overview. Academic Editor: K. Received 06 Nov Accepted 28 Nov Published 16 Dec Abstract We report a case of a year-old woman who presented with worsening dyspnea which rapidly progressed to severe heart failure. Introduction Myocarditis describes a group of heterogeneous disease processes that all involve inflammation of the myocardium. Case Report A year-old woman with no prior cardiac history presented in the springtime to an outside hospital with one month of progressive fatigue, palpitations, and exertional chest pain.

Figure 1. Figure 2. Chest plain film on presentation demonstrating likely pulmonary edema without cardiomegaly. Figure 3. Transthoracic echocardiogram before and after treatment with IVIG and steroids. The repeat transthoracic echocardiogram before treatment prior to discharge end diastole C and end systole D demonstrating a near complete resolution of ventricular systolic dysfunction.

Figure 4. Most infiltrating cells are mononuclear cells, admixed with occasional eosinophils. Figure 5. References I. Kindermann, C. Barth, F. Mahfoud et al. View at: Google Scholar S. Goland, L. Czer, R. Siegel et al. View at: Google Scholar L. Cooper, K. Baughman, A. Feldman et al. View at: Google Scholar H. Abdel-Aty, P. Zagrosek et al. View at: Google Scholar M. Mirabel, C. Luyt, P. Leprince et al. McNamara, R. Holubkov, R. Starling et al. View at: Google Scholar R. McCarthy, J. Boehmer, R.

Hruban et al. Cooper Jr. Hare, H. Tazelaar et al. Nunes, O. Freynet, N. Naggara et al. View at: Publisher Site Google Scholar. More related articles. Download other formats More.

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Steroids were not investigated as a single therapy. Mortality There were 34 deaths and 10 cardiac transplants among the patients. The immunosuppressino groups or control group did not differ in survival at one year. Base-line LVEF positively correlated with survival and the intensity of conventional therapy negatively correlated with survival.

Adverse drug effects Raised creatinine levels by at least 0. The incidence of new hypertension or severe infection did not differ between the groups. Camargo et al Brazil Among 68 consecutive patients with severe heart failure due to dilated cardiomyopathy, 43 had active myocarditis based on endomyocardial biopsy findings.

All patients presented with tachypnoea, tachycardia, sweating, gallop rhythm, pulmonary wheezing, rales and hepatomegaly. Patients were divided into four treatment groups depending on hospital admission sequence: I controls received conventional therapy ; II prednisolone with conventional therapy ; III azathioprine with conventional therapy and steroids ; and IV cyclosporine with conventional therapy and prednisolone.

Follow-up was for a mean of 8 months. Partially-randomised control study Clinical improvement disappearance of tachypnoea, rales, tachycardia, sweating and hepatomegaly 2 of 9 in control group; 3 of 12 in prednisolone group; 13 of 16 in azathioprine group; 10 of 13 in cyclosporine group. Very small groups within study.

Patients were moved between groups during the study, as such it is unclear how to include these patients in data interpretation. Incomplete randomisation and potential selection bias. Mortality 2 patients in the prednisolone group and one in both the cyclosporine and azathioprine groups. Haemodynamic response There were mild improvements in haemodynamic parameters in the control and prednisolone groups, but significant improvements in both the azathioprine and cyclosporine groups.

Histology One in four patients in the control group showed histological improvement. All 6 patients in the azathioprine group and all 4 in the cyclosporine group had no signs of myocardial inflammation at the end of treatment. A small number of patients were involved in the study with a limited follow-up period.

Follow-up period was 7 years. The children were divided into two groups: prednisolone group and placebo group. Randomised control study Mortality No significant difference in the short-term or long-term follow up. Small study group.

Only one dosage regime was used for prednisolone. Morbidity There was no significant difference, including the later requirement of valvular surgery. In addition, one third of cases improved with time regardless of treatment. The more favourable outcome was associated with initial mild to moderate disease.

Comment s The methodology within studies was overall poor and the samples sizes were small. There was considerable heterogeneity between studies. The advent of echocardiography has facilitated better evaluation of cardiac function, but the antiquity of the literature has meant that echography has been underused in the evaluation of cardiac function following myocarditis. The statistical significance of existing literature supporting the use of steroids is weak, while the adverse effects of steroids are well documented.

The disappointing results were similar between types of myocarditis viral, acute with pre-existing cardiomyopathy and rheumatic. Therefore, there is very little evidence to support the use of steroids in the management of myocarditis. Clinical Bottom Line There is very little evidence to support the efficacy of steroids in myocarditis. References Chen et al Corticosteroids for viral myocarditis. Cochrane Database Sytematic Review Cilliers et al Anti-inflammatory treatment for carditis in acute rheumatic fever.

Cochrane Database Sytematic Review Aziz et al Acute viral myocarditis: role of immunosuppression: a prospective randomised study. Cardiol Young Gagliardi et al Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart Frustaci et al Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders.

Circulation Frustaci et al Lone hepatitis C virus myocarditis responsive to immunosuppressive therapy. Chest Herdy et al Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years. Arg Bras Cardiol Kleinert et al Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression.

J Heart Lung Transplant. J Card Fail. The Myocarditis Treatment Trial Investigators. N Engl J Med. Pediatric Cardiology Maisch Immunosuppressive treatment in autoreactive myocarditis--results from a controlled trial. Postgrad Med J. Ann Trop Paediatr. Eight randomised controlled studies with participants were included. Non-significant mortality between corticosteroid groups and control groups RR 0.

Improved in corticosteroid group compared to control mean difference 7. Creatinine phosphokinase and isoenzme of creatinine phosphate MB were reduced in the corticosteroid group compared to the control group although there was small participation numbers. Eight randomised control studies involving patients were included. No significant difference in risk of cardiac disease between corticosteroids and aspirin relative risk 0.

Side effects were only described in three of the trials. Paediatric population 3. At one month, the prednisolone group increased ejection fraction from Event free survival was 0. No bacterial or viral infections were identified during the treatment cycle. This was correlated with histological evidence of relapsing myocarditis and improved with recommencing immunosuppression.

Patients treated with prednisolone and azathioprine for six months showed recovery of cardiac volumes and function. Of children with rheumatic fever between and , 70 cases with 76 episodes with active carditis treated with methyprednisolone were studied.

Prior to corticoid therapy, eradication of bacterial or parasitic infections and tuberculin tests were performed. Three children died during the pulse therapy, and one many years later during mitral valve replacement. All Group I patients regained normal left ventricular function compared to 4 of 18 group III patients. Patients with congestive heart failure of unknown aetiology underwent endomyocardial biopsy and radionuclide measurement of left ventricular ejection fraction. There was no difference in the incidence of all-cause death between the groups.

Those with positive histology and LVEF of The mean change in LVEF at 28 weeks did not differ significantly between the group of patients who received immunosuppression gain of 0. There were 34 deaths and 10 cardiac transplants among the patients. Raised creatinine levels by at least 0.

Among 68 consecutive patients with severe heart failure due to dilated cardiomyopathy, 43 had active myocarditis based on endomyocardial biopsy findings. Clinical improvement disappearance of tachypnoea, rales, tachycardia, sweating and hepatomegaly.

There were mild improvements in haemodynamic parameters in the control and prednisolone groups, but significant improvements in both the azathioprine and cyclosporine groups. The primary objective of this review is to assess the beneficial and harmful effects of treating acute or chronic viral myocarditis with corticosteroids. The secondary objective is to determine the best dose regimen. We applied no language restrictions. Selection criteria: Randomised controlled trials RCTs of corticosteroids for viral myocarditis compared with no intervention, placebo, supportive therapy, antiviral agents therapy or conventional therapy, including trials of corticosteroids plus other treatment versus other treatment alone, irrespective of blinding, publication status, or language.

Data collection and analysis: Two review authors extracted data independently. Main results: Eight RCTs with participants were included in this update. The trials were small in size and methodological quality was poor. Mortality between corticosteroids and control groups was non-significant RR, 0. At 1 to 3 months follow-up, left ventricular ejection fraction LVEF was higher in the corticosteroids group compared to the control group MD 7.

There were insufficient data on adverse events.

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Mason USA Patients with congestive heart failure of unknown aetiology underwent endomyocardial biopsy and radionuclide measurement of left ventricular ejection fraction. Those with positive histology and LVEF of Multi-centric randomised control study Left ventricular ejection fraction Both groups LVEF improved significantly by the end point of 28 weeks and continued through week However, there was no difference in LVEF improvement between the two groups or at any other point.

More severe disease at presentation correlated with more severe disease at follow-up. Small study group and complete data analysis did not distinguish between immunosuppressive regimes. Mortality There was no difference in the incidence of all-cause death between the groups. Mason et al USA Patients with congestive heart failure of unknown aetiology underwent endomyocardial biopsy and radionuclide measurement of left ventricular ejection fraction.

Those with positive histology and LVEF of Multi-centric randomised control study Left ventricular ejection fraction The mean change in LVEF at 28 weeks did not differ significantly between the group of patients who received immunosuppression gain of 0. LVEF at baseline, less intensive conventional drug therapy and shorter duration of disease were positive independent predictors of LVEF at week 28 weeks.

Relatively small study group. Steroids were not investigated as a single therapy. Mortality There were 34 deaths and 10 cardiac transplants among the patients. The immunosuppressino groups or control group did not differ in survival at one year. Base-line LVEF positively correlated with survival and the intensity of conventional therapy negatively correlated with survival. Adverse drug effects Raised creatinine levels by at least 0.

The incidence of new hypertension or severe infection did not differ between the groups. Camargo et al Brazil Among 68 consecutive patients with severe heart failure due to dilated cardiomyopathy, 43 had active myocarditis based on endomyocardial biopsy findings.

All patients presented with tachypnoea, tachycardia, sweating, gallop rhythm, pulmonary wheezing, rales and hepatomegaly. Patients were divided into four treatment groups depending on hospital admission sequence: I controls received conventional therapy ; II prednisolone with conventional therapy ; III azathioprine with conventional therapy and steroids ; and IV cyclosporine with conventional therapy and prednisolone.

Follow-up was for a mean of 8 months. Partially-randomised control study Clinical improvement disappearance of tachypnoea, rales, tachycardia, sweating and hepatomegaly 2 of 9 in control group; 3 of 12 in prednisolone group; 13 of 16 in azathioprine group; 10 of 13 in cyclosporine group. Very small groups within study.

Patients were moved between groups during the study, as such it is unclear how to include these patients in data interpretation. Incomplete randomisation and potential selection bias. Mortality 2 patients in the prednisolone group and one in both the cyclosporine and azathioprine groups.

Haemodynamic response There were mild improvements in haemodynamic parameters in the control and prednisolone groups, but significant improvements in both the azathioprine and cyclosporine groups. Histology One in four patients in the control group showed histological improvement. All 6 patients in the azathioprine group and all 4 in the cyclosporine group had no signs of myocardial inflammation at the end of treatment. A small number of patients were involved in the study with a limited follow-up period.

Follow-up period was 7 years. The children were divided into two groups: prednisolone group and placebo group. Randomised control study Mortality No significant difference in the short-term or long-term follow up. Small study group. Only one dosage regime was used for prednisolone.

Morbidity There was no significant difference, including the later requirement of valvular surgery. In addition, one third of cases improved with time regardless of treatment. The more favourable outcome was associated with initial mild to moderate disease. Comment s The methodology within studies was overall poor and the samples sizes were small.

There was considerable heterogeneity between studies. The advent of echocardiography has facilitated better evaluation of cardiac function, but the antiquity of the literature has meant that echography has been underused in the evaluation of cardiac function following myocarditis.

The statistical significance of existing literature supporting the use of steroids is weak, while the adverse effects of steroids are well documented. The disappointing results were similar between types of myocarditis viral, acute with pre-existing cardiomyopathy and rheumatic.

Therefore, there is very little evidence to support the use of steroids in the management of myocarditis. Clinical Bottom Line There is very little evidence to support the efficacy of steroids in myocarditis. References Chen et al Corticosteroids for viral myocarditis. Cochrane Database Sytematic Review Cilliers et al Anti-inflammatory treatment for carditis in acute rheumatic fever.

Cochrane Database Sytematic Review Aziz et al Acute viral myocarditis: role of immunosuppression: a prospective randomised study. Cardiol Young Gagliardi et al Long term follow up of children with myocarditis treated by immunosuppression and of children with dilated cardiomyopathy. Heart Frustaci et al Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders.

Circulation Frustaci et al Lone hepatitis C virus myocarditis responsive to immunosuppressive therapy. Chest Herdy et al Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years. Arg Bras Cardiol Kleinert et al Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression. J Heart Lung Transplant. J Card Fail. The Myocarditis Treatment Trial Investigators.

N Engl J Med. Pediatric Cardiology Maisch Immunosuppressive treatment in autoreactive myocarditis--results from a controlled trial. Postgrad Med J. Ann Trop Paediatr. Eight randomised controlled studies with participants were included.

Non-significant mortality between corticosteroid groups and control groups RR 0. Improved in corticosteroid group compared to control mean difference 7. Creatinine phosphokinase and isoenzme of creatinine phosphate MB were reduced in the corticosteroid group compared to the control group although there was small participation numbers.

Eight randomised control studies involving patients were included. No significant difference in risk of cardiac disease between corticosteroids and aspirin relative risk 0. Side effects were only described in three of the trials. Paediatric population 3. At one month, the prednisolone group increased ejection fraction from Event free survival was 0.

No bacterial or viral infections were identified during the treatment cycle. This was correlated with histological evidence of relapsing myocarditis and improved with recommencing immunosuppression. Patients treated with prednisolone and azathioprine for six months showed recovery of cardiac volumes and function. Of children with rheumatic fever between and , 70 cases with 76 episodes with active carditis treated with methyprednisolone were studied.

Prior to corticoid therapy, eradication of bacterial or parasitic infections and tuberculin tests were performed. The secondary objective is to determine the best dose regimen. We applied no language restrictions. Selection criteria: Randomised controlled trials RCTs of corticosteroids for viral myocarditis compared with no intervention, placebo, supportive therapy, antiviral agents therapy or conventional therapy, including trials of corticosteroids plus other treatment versus other treatment alone, irrespective of blinding, publication status, or language.

Data collection and analysis: Two review authors extracted data independently. Main results: Eight RCTs with participants were included in this update. The trials were small in size and methodological quality was poor.

Mortality between corticosteroids and control groups was non-significant RR, 0. At 1 to 3 months follow-up, left ventricular ejection fraction LVEF was higher in the corticosteroids group compared to the control group MD 7. There were insufficient data on adverse events. Authors' conclusions: For people diagnosed with viral myocarditis and low LVEF, corticosteroids do not reduce mortality.