Exploration of Cardiology

Table 3. Management of ICI-associated myocarditis by CTCAE severity grade.

CTCAE grade	Clinical features	ICI management	Immunosuppression	Cardiac support	References
Grade 1 (Asymptomatic)	Abnormal biomarkers or imaging only; no symptoms	Hold ICI; consider permanent discontinuation	Prednisone 1 mg/kg/day with taper	Serial monitoring of troponin, ECG, echo	[19, 33]
Grade 2 (Moderate)	Mild symptoms limiting instrumental ADLs	Permanently discontinue ICI	Methylprednisolone 1–2 mg/kg/day IV; consider escalation if no improvement in 24–48 hours	Cardiology consultation; standard HF therapy if needed	[19, 27, 48]
Grade 3 (Severe)	Severe symptoms requiring hospitalization	Permanently discontinue ICI	Pulse methylprednisolone 500–1,000 mg/day IV × 3–5 days, then taper; consider abatacept ± ruxolitinib if steroid-refractory	ICU monitoring; antiarrhythmics; temporary pacing if needed	[19, 27, 33, 48]
Grade 4 (Life-threatening)	Hemodynamic compromise, cardiogenic shock, malignant arrhythmias	Permanently discontinue ICI	Pulse methylprednisolone 1,000 mg/day IV; consider addition of abatacept + ruxolitinib; consider ATG, IVIG, or plasmapheresis	Mechanical circulatory support (IABP, ECMO, VAD); advanced HF/transplant consultation	[27, 33]

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Infliximab should be avoided or used with extreme caution in patients with reduced LVEF due to risk of exacerbating heart failure [27, 33]. ICI: immune checkpoint inhibitor; CTCAE: Common Terminology Criteria for Adverse Events; ECG: electrocardiogram; ADLs: activities of daily living; IV: intravenous; HF: heart failure; ATG: antithymocyte globulin; IVIG: intravenous immunoglobulin; IABP: intra-aortic balloon pump; ECMO: extracorporeal membrane oxygenation; VAD: ventricular assist device.

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Acknowledgments

Artificial intelligence–based tools (including large language models) were used to assist with drafting, language refinement, and organization of this manuscript. Open Evidence was used for literature search assistance while Claude (Anthropic) AI was used for writing support. All scientific content, interpretations, and conclusions were generated, verified, and approved by the author, who assumes full responsibility for the work.

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JV: Conceptualization, Investigation, Writing—original draft, Writing—review & editing. The author has read and approved the submitted version.

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