Study guide
13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy
ABIM Critical Care Medicine Study Guide Exam
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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy
1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy
2 Chapter 2: Acute Respiratory Failure & ARDS
2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO
3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies
3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage
4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies
4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome
5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation
5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support
6 Chapter 6: Shock Syndromes & Hemodynamic Principles
6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets
7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support
7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication
8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy
8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI
9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies
9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis
10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders
10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency
11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias
11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing
12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies
12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes
13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies
13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm
14 Chapter 14: Sepsis & Systemic Infectious Diseases
14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU
15 Chapter 15: ICU-Acquired & Severe Focal Infections
15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections
16 Chapter 16: Focal, Special-Host & Systemic Infections
16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses
17 Chapter 17: Neurocritical Care & Coma
17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage
18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States
18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy
19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness
19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination
20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis
20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis
21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies
21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia
22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis
22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes
23 Chapter 23: Trauma, Burns & Perioperative Critical Care
23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients
24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care
24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy
25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care
25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia
26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation
26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics
27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders
27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity
28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings
28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia
29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound
29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound
13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy
Key Takeaways Explain This Topic AI
Endomyocardial biopsy is indicated for fulminant or unexplained new heart failure with hemodynamic compromise, because giant cell myocarditis and eosinophilic myocarditis respond to immunosuppression.
Immune checkpoint inhibitor myocarditis carries high mortality and is treated with permanent drug discontinuation plus methylprednisolone 1,000 mg daily, escalating if there is no rapid response.
Takotsubo cardiomyopathy shows regional ballooning beyond a single coronary territory with a troponin rise that is modest relative to the wall-motion abnormality.
In hypertrophic cardiomyopathy with dynamic outflow obstruction, treat hypotension with fluids and phenylephrine and avoid inotropes, nitrates, and diuretic-driven preload loss.
Peripartum cardiomyopathy with an ejection fraction below about 30% carries a high risk of left ventricular thrombus, and anticoagulation is recommended during the peripartum period.
Last updated: October 2026
Fulminant Myocarditis
Myocarditis becomes a critical care problem when inflammation causes cardiogenic shock, high-grade conduction block, or ventricular arrhythmia . Patients are often young, with a viral prodrome, chest pain, and rapidly falling ejection fraction.
Causes :
Viral: enterovirus and coxsackie, adenovirus, parvovirus B19, human herpesvirus 6, influenza, SARS-CoV-2.
Immune: giant cell myocarditis, eosinophilic (hypersensitivity) myocarditis, sarcoidosis, systemic lupus, and immune checkpoint inhibitor myocarditis.
Toxic: anthracyclines, 5-fluorouracil, cocaine, methamphetamine.
Bacterial and other: Lyme carditis, diphtheria, Chagas disease.
Diagnosis :
Troponin is usually markedly elevated with a non-obstructive coronary angiogram.
Echocardiography shows global or regional dysfunction, sometimes with increased wall thickness from edema.
Cardiac MRI shows edema and late gadolinium enhancement, typically subepicardial.
Endomyocardial biopsy is indicated for fulminant presentations, because it identifies the subtypes that need immunosuppression.
Management :
Standard cardiogenic shock care, but with a low threshold for temporary mechanical circulatory support (Impella, VA-ECMO), because many patients recover ventricular function within weeks.
Avoid NSAIDs; use guideline heart failure therapy once stabilized.
Treat arrhythmia aggressively; high-grade block may need temporary pacing, and definitive device decisions are deferred until recovery is assessed.
Specific immunosuppression :
Giant cell myocarditis : corticosteroids plus cyclosporine, often with azathioprine; untreated, it progresses to death or transplantation.
Eosinophilic myocarditis : stop the triggering drug and give corticosteroids.
Cardiac sarcoidosis : corticosteroids, with device therapy for conduction disease.
Lyme carditis : ceftriaxone, with temporary pacing for block that usually resolves.
Immune checkpoint inhibitor myocarditis : suspect it within the first few weeks of therapy, often with concomitant myositis and a high creatine kinase. Stop the drug permanently and give methylprednisolone 1,000 mg daily ; escalate to abatacept, mycophenolate, antithymocyte globulin, or plasma exchange if there is no rapid improvement. Mortality is high, and conduction disease is common.
Stress (Takotsubo) Cardiomyopathy
Triggers : emotional or physical stress, subarachnoid hemorrhage, status epilepticus, severe sepsis, catecholamine infusions, pheochromocytoma, and withdrawal states.
Features :
Chest pain, dyspnea, or shock with ST elevation or deep T-wave inversion and marked QT prolongation.
Regional ballooning across more than one coronary territory , most often apical, sometimes midventricular or basal (the "reverse" variant).
A troponin rise that is modest relative to the extent of dysfunction , with a disproportionately high BNP.
Non-obstructive coronaries.
Complications : dynamic left ventricular outflow obstruction, severe mitral regurgitation, apical thrombus, free wall rupture (rare), and ventricular arrhythmia from QT prolongation.
Management : supportive. If there is outflow obstruction, avoid inotropes and use phenylephrine and fluids; otherwise standard heart failure therapy. Recovery within days to weeks is typical. Anticoagulate for apical thrombus or akinesis with high thrombus risk. Watch for recurrence.
Peripartum Cardiomyopathy
Definition : new systolic dysfunction toward the end of pregnancy or in the months after delivery, without another cause.
Risk factors : older maternal age, multiparity, preeclampsia and hypertensive disorders, multiple gestation, and African ancestry.
Presentation : heart failure that mimics normal late-pregnancy symptoms, so diagnosis is often delayed; some present in cardiogenic shock or with arrhythmia.
Management :
Before delivery , avoid ACE inhibitors, ARBs, ARNI, mineralocorticoid antagonists, and ivabradine. Hydralazine and nitrates control afterload, beta-1 selective beta-blockers (metoprolol) are used, and furosemide is given for congestion.
After delivery , use full guideline-directed therapy; ACE inhibitors such as enalapril and captopril, and beta-blockers, are compatible with breastfeeding.
Anticoagulation is recommended for an ejection fraction below about 30% in the peripartum period, because thrombosis risk is high.
Bromocriptine to suppress prolactin has shown benefit in trials and registries, and must be combined with anticoagulation; it precludes breastfeeding and remains individualized.
Severe shock needs mechanical circulatory support and transplant evaluation; many patients recover ejection fraction within 6 months.
Counsel that subsequent pregnancy carries substantial relapse risk, particularly if function has not normalized.
Hypertrophic Cardiomyopathy in the ICU
The problem is a small, stiff, hypercontractile ventricle with dynamic outflow obstruction worsened by anything that reduces cavity size: hypovolemia, vasodilation, tachycardia, and inotropes.
- Intervention Effect in obstructive hypertrophic cardiomyopathy
- Volume loading Helps by increasing preload and cavity size
- Phenylephrine or norepinephrine Helps by raising afterload and reducing the gradient
- Beta-blockers Help by slowing rate and improving filling
- Nitroglycerin, nitroprusside, ACE inhibitors Harm by lowering afterload and increasing obstruction
- Dobutamine, milrinone, epinephrine, digoxin Harm by increasing contractility and obstruction
- Aggressive diuresis Harms by reducing preload
- Positive pressure ventilation May reduce preload; use cautiously
Atrial fibrillation is poorly tolerated because the atrial kick is lost and rate rises. Cardiovert early, and anticoagulate (hypertrophic cardiomyopathy with atrial fibrillation is an indication regardless of the CHA2DS2-VASc score).
Sudden cardiac death risk factors include unexplained syncope, massive wall thickness (30 mm or more), a family history of sudden death, nonsustained ventricular tachycardia, apical aneurysm, and extensive late gadolinium enhancement.
Rescue options for refractory obstruction include disopyramide, septal reduction (myectomy or alcohol ablation), and cardiac myosin inhibitors in the outpatient setting.
In hypertrophic cardiomyopathy with cavity obliteration and hypotension on the ventilator, the management is counterintuitive: fluid, pure vasoconstrictors, rate control, and sedation to reduce catecholamines, rather than inotropic escalation.