Can acute pericarditis present with elevated troponin (cardiac biomarker) and B-type natriuretic peptide (BNP) levels?

Cardiac Biomarkers in Acute Pericarditis

Yes, acute pericarditis can present with elevated troponin and BNP levels, particularly when there is myocardial involvement (myopericarditis). According to current guidelines, this is a recognized clinical entity with specific diagnostic and prognostic implications.

Myopericarditis: When Pericarditis Involves the Myocardium

Definition and Diagnosis

• Pericarditis with myocardial involvement (myopericarditis) occurs when inflammation extends beyond the pericardium to affect the myocardium 1
• Diagnostic criteria include:
  • Clinical features of acute pericarditis (chest pain, pericardial rubs, ST-segment elevation, pericardial effusion)
  • PLUS elevation of cardiac biomarkers (troponin I or T, CK-MB) 1
  • WITHOUT newly developed focal or diffuse impairment of left ventricular function 1

Biomarker Patterns

Troponin Elevation

• Troponin elevation occurs in approximately 49% of patients with acute pericarditis 2
• Significant troponin elevation (>1.5 ng/mL) is seen in about 22% of pericarditis cases 2
• Troponin elevation indicates myocardial involvement and defines the condition as myopericarditis 1
• ST-segment elevation is more common in patients with elevated troponin (93% vs 57%) 2

BNP Elevation

• BNP or NT-proBNP can be elevated in acute pericarditis, particularly when there is:
  • Hemodynamic compromise
  • Myocardial involvement
  • Underlying cardiac dysfunction 3
• BNP testing is recommended as part of the diagnostic workup in patients with suspected pericarditis 3

Clinical Implications

Prognostic Significance

• The overall prognosis of myopericarditis is generally good despite troponin elevation 4
• Mortality is rare in myopericarditis, with most studies reporting no deaths during follow-up 4
• Residual left ventricular dysfunction occurs in only about 3.5% of patients 4
• Recurrences (mainly as recurrent pericarditis) occur in approximately 13% of cases 4

Risk Stratification

• Patients with both elevated troponin and BNP may represent a higher-risk group 5
• The European Society of Cardiology recommends cardiac biomarker testing to identify myocardial involvement 1, 3
• Patients with myopericarditis should be hospitalized for diagnosis and monitoring 1

Management Considerations

Diagnostic Approach

• All patients with suspected pericarditis should have:
  • Inflammatory markers (CRP, ESR, WBC)
  • Renal and liver function tests
  • Cardiac biomarkers (troponin, CK)
  • Thyroid function tests 3
• Echocardiography to evaluate for pericardial effusion and cardiac function 3
• Consider cardiac MRI in patients with elevated troponin to confirm myocardial involvement 1, 3
• Coronary angiography may be warranted to rule out acute coronary syndromes in patients with significant troponin elevation 1

Treatment Modifications

• For myopericarditis, management is similar to pericarditis but with some caution regarding NSAID dosing 1
• Some experts recommend reduced dosages of NSAIDs in myopericarditis compared to pure pericarditis 1
• Empirical anti-inflammatory therapy with aspirin (1500-3000 mg/day) or NSAIDs (ibuprofen 1200-2400 mg/day) is recommended 1
• Colchicine should be added to improve response and prevent recurrences 3
• Physical activity restriction is important until symptoms resolve and biomarkers normalize 3

Important Caveats

• Troponin elevation in pericarditis does not necessarily indicate poor prognosis 4
• Elevated cardiac biomarkers require differentiation from acute coronary syndromes 1
• Troponin levels may initially be normal and rise later in the course of myopericarditis 6
• Patients with both elevated troponin and normal BNP despite severe clinical presentation may have worse outcomes in fulminant cases 5

In clinical practice, recognition of biomarker elevation patterns helps distinguish between uncomplicated pericarditis and myopericarditis, guiding appropriate management and follow-up strategies.