Immune Checkpoint Inhibitor-Associated Myocarditis Presenting as Isolated High-Grade Atrioventricular Block: A Review of Surveillance Strategies
DOI:
https://doi.org/10.5281/zenodo.22205984Keywords:
Immune Checkpoint Inhibitor, Myocarditis, Atrioventricular Block, Troponin SurveillanceAbstract
Myocarditis is the least common and most lethal cardiovascular toxicity of immune checkpoint blockade. It declares itself early, often after a single dose, and a substantial minority of patients present with conduction disease rather than heart failure, so surveillance built around symptoms and ventricular function will miss them. Objectives: To review the evidence on the incidence, timing and presenting features of immune checkpoint inhibitor (ICI) myocarditis, with attention to the conduction-first phenotype, and to assess what troponin, electrocardiographic and imaging surveillance can and cannot achieve in an ambulatory oncology population.
Material and Methods: A narrative review. MEDLINE, Embase and the Cochrane Library were searched from January 2015 to May 2026 for registry and cohort studies, pharmacovigilance analyses, diagnostic accuracy studies, consensus definitions and society guidance. Incidence figures, event rates and diagnostic yields were extracted from the primary reports without pooling. Results: Reported incidence ranges from 0.04% to 1.14% and case fatality from 25% to 50%; of 122 pharmacovigilance reports of myocarditis,
50% were fatal against 21% for pericardial disease and 6% for vasculitis. Median onset is 34 days and roughly two-thirds of patients have had only one or two cycles. Major adverse cardiac events occur in 38-46% of cases, and high-grade atrioventricular block is both a component of that composite and an independent predictor of death. Late gadolinium enhancement was present in only 48% of an international magnetic resonance cohort, with yield rising from 21.6% to 72.0% according to scan timing.nConclusion: Troponin is the only instrument sensitive and practical enough to anchor a programme, but it must be paired with a baseline and serial electrocardiogram, because the conduction-first presentation can occur with modest troponin elevation and normal ventricular function. A protocolised pathway with a pre-specified action threshold is what converts surveillance into earlier treatment.
Abbreviations: ICI – Immune Checkpoint Inhibitor, irAE – Immune-Related Adverse Event, MACE – Major Adverse Cardiac Events, CMR –
Cardiovascular Magnetic Resonance, LGE – Late Gadolinium Enhancement, STIR – Short Tau Inversion Recovery.
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