Therapeutic management of inflammatory heart diseases

Inflammatory heart diseases include a wide range of clinical entities whose manifestations largely depend on whether the pericardium, myocardium, and/or endocardium are affected by infectious agents or sterile inflammation. Advancements in understanding the inflammatory pathogenesis of pericarditis have led to the successful development of targeted anti-inflammatory therapies. While non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine remain first-line therapeutic options in those with acute pericarditis, interleukin-1 (IL-1) inhibitors have been recently approved for the treatment of recurrent/refractory pericarditis. Myocarditis is currently managed with supportive care, with glucocorticoids and immunosuppression being considered for virus-negative cases, especially when cardiac function is depressed or in cases of known underlying autoimmune disease. Coronary involvement may occur in systemic vasculitides - including Kawasaki disease (up to 20% of affected subjects), Takayasu arteritis (10-30%), polyarteritis nodosa (50%), and giant cell arteritis (<1%). Treatment of coronary arteritis generally includes high-dose glucocorticoids, followed by immunosuppressive drugs. Non-infective endocarditis may present in association with cancer or autoimmune disorders, such as systemic lupus erythematosus (Libman-Sacks endocarditis). Management of non-infective endocarditis generally encompasses treatment of the underlying disease, including surgery in selected cases. Cardiac imaging, particularly cardiac magnetic resonance and ¹⁸F-fluorodeoxyglucose positron emission tomography, are helpful for non-invasive tissue evaluation and areas of high metabolic activity, respectively. Newer techniques, such as fat attenuation index, are likely to be further additive and may reduce diagnostic delay of coronary inflammation. In the above-mentioned conditions, targeted anti-cytokine therapies can selectively address key pathogenic mechanisms more safely and effectively than broad, nonselective immunosuppressants. Additional research is needed to establish novel molecular targets and improve phenotyping and risk stratification of patients with inflammatory heart diseases, ultimately enabling precision and personalized treatment approaches.