EM · Myocarditis & pericarditis
Myocarditis and pericarditis (the ACS mimic and the positional chest pain)
Also known as Myopericarditis · Acute pericarditis · Viral pericarditis · Myocarditis
Myocarditis and pericarditis — the viral or the autoimmune inflammation of the heart muscle and the pericardium, the clinical presentation (the positional and the pleuritic chest pain of the pericarditis; the ACS-mimic and the arrhythmia of the myocarditis), the ECG pattern (the diffuse ST elevation and the PR depression of the pericarditis), the troponin elevation (in both), the management (the NSAID and the colchicine for the pericarditis; the supportive and the heart-failure therapy for the myocarditis), and the fulminant myocarditis needing the mechanical support. ACEM-primary, globally tagged.
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- Myocarditis can mimic an acute coronary syndrome exactly — the chest pain, the ECG changes and the troponin rise may be indistinguishable from an infarct
- A fulminant myocarditis presents as a cardiogenic shock or a ventricular arrhythmia in a young, previously well patient — it needs the mechanical circulatory support and the intensive care
- A pericarditis with a large pericardial effusion may progress to a tamponade — monitor with the serial echocardiography
- The athlete with a myocarditis is at a high risk of the sudden cardiac death — the return to the sport is restricted for 3 to 6 months
- A recurrent pericarditis (over 30 per cent after the first episode) is the commonest complication — the colchicine reduces the recurrence rate
Meet the patient
A 28-year-old competitive amateur footballer, previously well, presents with twelve hours of central chest pain, breathlessness and palpitations. He describes a flu-like illness with fever, myalgia and diarrhoea a week earlier. He has no coronary risk factors and does not smoke. He is febrile, tachycardic, hypotensive, with bilateral basal crackles and a raised JVP. The ECG shows two millimetres of concave ST elevation in leads I, aVL and V3 to V6 with PR-segment depression. The troponin is 1850. The chest X-ray shows pulmonary venous congestion.[1]
The two questions that decide his next two hours are the two that decide every myocarditis-versus-ACS encounter: is this a plaque rupture or an inflamed myocardium? (the ECG morphology and the angiography answer that) and is this heart failing fast? (the echo and the lactate answer that). Treat him as a STEMI until proven otherwise, then let the normal coronaries and the MRI tell you it was myocarditis all along.[1]
References14ShowHide
- [1]Coaxum L, McClean C, Theophanous R Myopericarditis in an emergency department patient presenting with chest pain and ECG changes: a case report Egypt Heart J, 2026.PMID 41945202
- [2]Charron P, Adler Y 'Ten Commandments' of 2015 ESC Guidelines for diagnosis and management of pericardial diseases Eur Heart J, 2015.PMID 26866075
- [3]Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS) Eur Heart J, 2015.PMID 26320112
- [4]Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases Eur Heart J, 2013.PMID 23824828
- [5]Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper J Am Coll Cardiol, 2009.PMID 19389557
- [6]Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations J Am Coll Cardiol, 2018.PMID 30545455
- [7]Kociol RD, Cooper LT, Fang JC, et al. Recognition and Initial Management of Fulminant Myocarditis: A Scientific Statement From the American Heart Association Circulation, 2020.PMID 31902242
- [8]Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial Circulation, 2005.PMID 16186437
- [9]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
- [10]McCarthy RE 3rd, Boehmer JP, Hruban RH, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis N Engl J Med, 2000.PMID 10706898
- [11]Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment Circulation, 2006.PMID 16476862
- [12]Aretz HT. Myocarditis: the Dallas criteria Hum Pathol, 1987.PMID 3297992
- [13]Oster ME, Shay DK, Su JR, et al. Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021 JAMA, 2022.PMID 35076665
- [14]Imazio M, Trinchero R, Brucato A, et al. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial Eur Heart J, 2010.PMID 20805112