Arrhythmic myocarditis and prevention of sudden cardiac death: current evidence, risk stratification, and management

Myocarditis is an inflammatory myocardial disease with heterogeneous clinical manifestations ranging from chest pain to cardiogenic shock and malignant ventricular arrhythmias. Arrhythmic presentations represent an important clinical phenotype associated with increased risk of sudden cardiac death (SCD). Contemporary studies suggest that ventricular arrhythmias occur in approximately 10% of hospitalized patients with acute myocarditis, frequently during the early inflammatory phase. Risk stratification requires integration of clinical presentation, ventricular function, arrhythmic burden, genetic variants, and findings on cardiac magnetic resonance imaging such as late gadolinium enhancement. Management strategies include treatment of the underlying inflammatory process, guideline-directed heart failure therapy, anti-arrhythmic drugs, catheter ablation in selected cases, and implantable cardioverter-defibrillators for primary and secondary prevention. This review summarizes current evidence regarding epidemiology, mechanisms, risk stratification, and prevention of sudden cardiac death in patients with arrhythmic myocarditis and highlights emerging concepts in imaging, genetics, and personalized management.