Spotting Myocarditis in the ED: Viral Fallout 

-Case-

A 27-year-old previously healthy male presents with pleuritic chest pain, low-grade fever, and shortness of breath for 2 days. His EKG shows nonspecific ST changes and his troponin is slightly elevated. He denies recent travel or known sick contacts but does recall having a viral illness about a week ago. He looks anxious, his HR is 108, BP 100/60, and oxygen sat 96% on RA. 

-Evaluation-

Myocarditis is inflammation of the heart muscle, often caused by viral infections (coxsackievirus, adenovirus, parvovirus B19, influenza, and yes, SARS-CoV-2). It can also stem from autoimmune disease, toxins, or medications.

Presentation is wildly variable. It ranges from flu-like symptoms to fulminant cardiogenic shock. The key is not overlooking this pathology, especially in:

• Young patients with recent viral illness
• Chest pain + elevated troponin with non-obstructive CAD or normal cath
• New-onset heart failure
• Arrhythmias or unexplained syncope

Diagnosis:

• EKG: often shows nonspecific ST-T changes; may mimic pericarditis or STEMI
• Troponin: frequently elevated but not in a classic MI pattern
• BNP/pro-BNP: may be elevated if heart failure is developing
• CXR: can be normal or show signs of pulmonary edema
• Echocardiogram: can show reduced EF, wall motion abnormalities, or pericardial effusion
• Cardiac MRI: most sensitive non-invasive test; can detect myocardial edema and fibrosis
• Endomyocardial biopsy: gold standard but this will (probably) never happen in the ED

-Management-

Supportive care is the cornerstone!

• If signs of heart failure: start gentle diuresis, consider ACE inhibitors and beta-blockers
• Avoid NSAIDs in myocarditis unless pericarditis is predominant
• Avoid exercise! Patients need to rest that inflamed myocardium
• Cardiology consult for uncertain diagnosis or hemodynamic instability
• Admit for telemetry monitoring if any signs of arrhythmia, HF, or elevated biomarkers

-Fast Facts-

• Viral myocarditis is a leading cause of sudden cardiac death in young adults
• A “normal” EKG doesn’t rule it out
• Consider myocarditis in young patients with unexplained chest pain and elevated troponin
• Early cardiology involvement is crucial

Myocarditis loves to fly under the radar until it doesn’t. When a young, healthy patient shows up with chest pain and a viral prodrome, don’t brush it off. Check that troponin, trust your spidey sense, and don’t forget: if the cath is clean, think inflammation.

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

-References-

1. Caforio ALP, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis. Eur Heart J. 2013;34(33):2636-2648. doi:10.1093/eurheartj/eht210
2. Ammirati E, Frigerio M, Adler ED, et al. Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document. Circulation: Heart Failure. 2020;13(11):e007405. doi:10.1161/CIRCHEARTFAILURE.120.007405
3. Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial inflammation: Expert recommendations. J Am Coll Cardiol. 2018;72(24):3158-3176. doi:10.1016/j.jacc.2018.09.072
4. Bozkurt B, Colvin M, Cook J, et al. Current diagnostic and treatment strategies for specific dilated cardiomyopathies: a scientific statement from the American Heart Association. Circulation. 2016;134(23):e579-e646. doi:10.1161/CIR.0000000000000455
5. Lüers C, Klingel K, Egerer R, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. 2007;115(23):2938-2945. doi:10.1161/CIRCULATIONAHA.106.666263