What is the treatment for myopericarditis?

Treatment of Myopericarditis

The treatment of myopericarditis should follow a similar approach to pericarditis, with empirical anti-inflammatory therapies such as aspirin (1500-3000 mg/day) or NSAIDs (ibuprofen 1200-2400 mg/day or indomethacin 75-150 mg/day) as first-line treatment to control chest pain, while rest and avoidance of physical activity are essential components of management. 1

Diagnosis and Initial Evaluation

Myopericarditis is defined as pericarditis with myocardial involvement, characterized by:

• Clinical criteria for acute pericarditis
• Elevated biomarkers of myocardial injury (troponin I or T, CK-MB)
• Absence of newly developed focal or diffuse impairment of left ventricular function 1, 2

Diagnostic steps include:

• Coronary angiography (based on clinical presentation and risk factors) to rule out acute coronary syndromes
• Cardiac magnetic resonance imaging to confirm myocardial involvement
• Hospitalization for diagnosis and monitoring 1

Treatment Algorithm

First-Line Treatment

• Anti-inflammatory therapy:
  • Aspirin 1500-3000 mg/day OR
  • NSAIDs: ibuprofen 1200-2400 mg/day OR indomethacin 75-150 mg/day
  • Consider lower doses compared to pure pericarditis 1, 3
  • Primary goal: symptom control, particularly chest pain

Second-Line Treatment

• Corticosteroids should be considered only in cases of:
  • Contraindication to NSAIDs/aspirin
  • Intolerance to first-line therapy
  • Failure of aspirin/NSAIDs 1

Additional Management

• Mandatory rest and physical activity restriction:

  • Avoid physical activity beyond normal sedentary activities
  • Continue restriction for at least 6 months from onset of illness 1, 2
  • This is particularly important as sudden cardiac death cases have been reported in athletes and military personnel after strenuous exertion 1

• Monitoring:

  • C-reactive protein (CRP) should be considered to guide treatment duration and assess response 1
  • Follow-up echocardiography to monitor cardiac function 3

Special Considerations

• Colchicine: There are insufficient data to recommend its use in myopericarditis, despite being well-established for acute and recurrent pericarditis 1

• Caution with NSAIDs: Some animal studies suggest NSAIDs may be ineffective or potentially harmful in pure myocarditis, but this may not directly apply to humans with myopericarditis 1, 3

• Return to physical activity: While patients with isolated pericarditis may return to exercise when there's no evidence of active disease, those with myocardial involvement should avoid physical exercise for at least 6 months 1

Prognosis

Myopericardial involvement generally has a good prognosis. Multiple observational series have demonstrated no evolution to heart failure or mortality in patients with myopericarditis 1, 2. Complete remission is typically seen within 3-6 months 2.

Common Pitfalls to Avoid

1. Failure to distinguish from acute coronary syndrome: Ensure proper diagnostic workup including coronary angiography when appropriate

2. Premature return to physical activity: This can lead to serious complications including sudden cardiac death

3. Overuse of corticosteroids: These should not be first-line treatment for myopericarditis

4. Inadequate rest period: Patients need strict activity restriction for at least 6 months, regardless of symptom resolution

5. Missing concomitant conditions: Some cases may present with isolated right ventricular failure, which is rare but possible 4