Evaluation and Management of Chest Pain Post-Influenza

Immediate Diagnostic Workup

Obtain a 12-lead ECG within 10 minutes of presentation to identify ST-segment elevation, widespread ST-elevation with PR depression, or low-voltage QRS with electrical alternans, as recommended by the American Heart Association 3, 1
Measure cardiac troponin immediately, as myocarditis following influenza can present with troponin elevation mimicking acute coronary syndrome, according to the American College of Cardiology 1
Order chest radiography to evaluate for pneumonia, pleural effusion, pneumothorax, or cardiomegaly suggesting pericardial effusion, as suggested by the American College of Radiology 1

Influenza-associated myocarditis can present with chest pain, ST-segment elevation, and troponin elevation mimicking acute coronary syndrome, even with normal coronary angiography, as noted by the American Heart Association 1, 2
Sharp, pleuritic chest pain that improves when sitting forward and worsens when supine is characteristic of pericarditis, according to the European Society of Cardiology 1, 2

Retrosternal pressure-type discomfort radiating to left arm/jaw/neck with diaphoresis, dyspnea, or nausea suggests acute coronary syndrome, as recommended by the American College of Cardiology 2
Presents with acute dyspnea, pleuritic chest pain, tachycardia, and tachypnea, which are symptoms of pulmonary embolism, according to the American Thoracic Society 1, 2
Use validated clinical decision rules, such as the Wells score or PERC rule, to determine pretest probability and guide D-dimer testing for pulmonary embolism, as suggested by the American College of Chest Physicians 1

Obtain transthoracic echocardiography to assess for pericardial effusion, ventricular wall motion abnormalities, or restrictive physiology in patients with suspected pericarditis or myocarditis, as recommended by the American Society of Echocardiography 1
Cardiac MRI with gadolinium contrast distinguishes myopericarditis from other causes, including myocardial infarction with nonobstructive coronary arteries, when myocardial injury is present, according to the Society for Cardiovascular Magnetic Resonance 1

If ECG shows ST elevation, new ischemic changes, or signs of tamponade, arrange immediate transfer by EMS to the emergency department, as recommended by the American College of Emergency Physicians 2, 4
For confirmed pericarditis, treatment includes NSAIDs and colchicine, and steroids may be needed for refractory cases, according to the European Society of Cardiology 5, 2