What is the management for chest pain secondary to a viral infection?

Management of Chest Pain Secondary to Viral Infection

Patients with chest pain secondary to viral infection should be managed based on clinical presentation, with those having chest pain as their only symptom, preserved left ventricular function, and no ventricular arrhythmias typically managed in the ambulatory setting with close monitoring for worsening symptoms. 1

Initial Assessment and Diagnosis

Types of Viral-Associated Chest Pain

• Musculoskeletal chest pain due to viral myositis (e.g., enterovirus epidemic myalgia/pleurodynia/Bornholm disease) 1
• Pericarditis - sharp, pleuritic chest pain that worsens when supine 2
• Myocarditis - can present with chest pain similar to angina 1
• Pleuritic chest pain - sharp, stabbing pain with breathing, common with respiratory viral infections 3

Diagnostic Approach

1. ECG - Look for:

   • Diffuse ST-segment elevation without reciprocal depression
   • PR depression
   • T-wave inversion 1, 2

2. Laboratory tests:

   • Cardiac troponin - elevated in myocarditis
   • C-reactive protein - elevated in inflammatory conditions
   • BNP/NT-proBNP - if heart failure is suspected 1

3. Imaging:

   • Echocardiogram - to assess ventricular function and rule out pericardial effusion
   • Chest X-ray - to evaluate for pneumonia or other pulmonary causes
   • Consider cardiac MRI if myocarditis is suspected and patient is hemodynamically stable 1

Management Algorithm

1. Mild Presentation (Outpatient Management)

For patients with:

• Chest pain as only symptom
• Preserved left ventricular function
• No ventricular arrhythmias 1

Treatment:

• NSAIDs - high-dose regimen (e.g., ibuprofen 600-800 mg three times daily) as first-line therapy 2, 4
• Rest and adequate hydration
• Heat application to affected areas
• Oral analgesics if needed for pain control
• Patient education about warning signs requiring urgent medical attention 1

2. Moderate Presentation (Consider Hospitalization)

For patients with:

• Persistent chest pain despite NSAIDs
• Mild troponin elevation (<2-3 times upper limit of normal)
• Abnormal ECG findings
• Small pericardial effusion 1, 2

Treatment:

• NSAIDs at anti-inflammatory doses
• Colchicine (0.5-0.6 mg twice daily) - particularly if pericarditis is suspected 2, 4
• Close monitoring for clinical deterioration
• Follow-up testing in 3-6 months (ECG, echocardiogram) 1

3. Severe Presentation (Requires Hospitalization)

For patients with:

• Hemodynamic instability
• Significant troponin elevation (>5 times upper limit of normal)
• Ventricular arrhythmias
• Heart block
• Reduced left ventricular function
• Moderate-to-large pericardial effusion 1

Treatment:

• Hospitalization at an advanced heart failure center
• Corticosteroids if myocarditis with COVID-19 pneumonia requiring oxygen 1
• Mechanical circulatory support for cardiogenic shock
• Consider endomyocardial biopsy in deteriorating patients with heart block or ventricular arrhythmias 1

Special Considerations

COVID-19 Associated Chest Pain

• COVID-19 can cause myocardial injury through direct viral invasion or immune-mediated inflammation 1, 5
• Continue pre-existing antihypertensive medications including ACE inhibitors/ARBs 6
• Higher suspicion for thrombotic complications including pulmonary embolism 6

Warning Signs Requiring Urgent Evaluation

• Shortness of breath
• Syncope or presyncope
• Edema
• Persistent fever
• Worsening chest pain despite treatment 1

Follow-up Care

• Consider follow-up cardiac testing (ECG, echocardiogram, ambulatory rhythm monitor, CMR) 3-6 months after presentation for patients with:
  • Ongoing cardiac symptoms
  • Findings suggestive of significant myocardial involvement 1

Pitfalls and Caveats

• Do not delay appropriate treatment for suspected cardiac complications even if COVID-19 is confirmed 6
• Avoid excessive hydration in patients with myocarditis to prevent volume overload 1
• Do not miss other serious causes of chest pain such as pulmonary embolism, which is found in 5-21% of patients presenting with pleuritic chest pain 3
• NSAIDs should be tapered once chest pain resolves and inflammatory markers normalize 2

By following this structured approach based on clinical presentation and severity, most patients with viral-associated chest pain can be effectively managed with good outcomes.