Diagnostic Approach to Myocarditis and Pericarditis
Initial Evaluation
- The European Society of Cardiology recommends immediate ECG, transthoracic echocardiography, chest X-ray, and blood tests including inflammatory markers and cardiac injury markers for all patients with suspected myocarditis or pericarditis 1, 2, 3
- Auscultation for pericardial friction rub is essential in the clinical assessment of patients with suspected pericarditis 3, 4
- Patients with suspected myocarditis should be assessed for symptoms such as dyspnea, fatigue, palpitations, syncope, or chest pain mimicking acute MI 5, 6
Laboratory Tests
- Inflammatory markers such as CRP and/or ESR, white blood cell count with differential are crucial in the diagnosis of myocarditis and pericarditis 1, 2, 3
- Cardiac injury markers such as Troponin I/T and creatine kinase are essential in the diagnosis of myocarditis 1, 2, 6, 7
- Troponin elevation suggests myocardial involvement, but normal values do not exclude disease 1, 2, 6, 7
Imaging Studies
- Transthoracic echocardiography is critical for assessing pericardial effusion, cardiac tamponade, wall motion abnormalities, ventricular function, and wall thickness 1, 2, 3
- Chest X-ray is useful for identifying pericardial effusion and pleuro-pulmonary involvement 1, 2, 3
Risk Stratification
- The European Heart Journal guidelines state that patients with high-risk features such as fever, subacute course, large pericardial effusion, cardiac tamponade, or failure to respond to NSAIDs require hospital admission 1, 2, 8, 10
- Minor risk factors such as myopericarditis, immunosuppression, trauma, or oral anticoagulant therapy may also require hospitalization 1, 10
Second-Level Testing
- Cardiac Magnetic Resonance (CMR) is recommended as second-level imaging for both pericarditis and myocarditis 8, 3, 4
- CMR is highly sensitive for detecting epicardial or mid-wall delayed gadolinium enhancement and myocardial edema on T2-weighted sequences in myocarditis 5, 9
Treatment
- The European Heart Journal recommends first-line therapy with aspirin or NSAIDs plus colchicine for 3 months in patients with pericarditis 11, 4, 10
- Corticosteroids are not recommended as first-line therapy for pericarditis due to increased recurrence risk 11, 4, 10
- Treatment of myocarditis should focus on addressing heart failure and arrhythmias, and specific immunosuppressive therapy may be necessary for certain etiologies 6, 7