From the Guidelines
The investigation and management of myopericarditis involves a comprehensive approach combining diagnostic testing and targeted treatment, with hospitalization recommended for diagnosis and monitoring of patients with myocardial involvement and differential diagnosis, especially with acute coronary syndromes, as stated in the 2015 ESC guidelines 1. The initial evaluation should include:
- Electrocardiogram (ECG)
- Cardiac biomarkers (troponin, CK-MB)
- Inflammatory markers (ESR, CRP)
- Echocardiography to assess cardiac function and pericardial effusion Cardiac MRI is the gold standard for confirming the diagnosis, showing characteristic late gadolinium enhancement, as recommended in the 2015 ESC guidelines 1. Additional tests may include viral studies and occasionally endomyocardial biopsy in unclear cases. Treatment focuses on managing inflammation with:
- NSAIDs such as ibuprofen (1200 – 2400 mg/day) or aspirin (1500 – 3000 mg/day) for 1-2 weeks with gradual tapering, as recommended in the 2015 ESC guidelines 1
- Colchicine (0.5mg twice daily for 3-6 months) is often added to reduce recurrence, as recommended in the 2015 ESC guidelines 1
- Corticosteroids like prednisone (0.25-0.5mg/kg/day) may be necessary for severe cases, as recommended in the 2015 ESC guidelines 1 Complete rest and abstinence from physical activity for 3-6 months is crucial to prevent complications, as recommended in the 2015 ESC guidelines 1. Patients should avoid alcohol and receive standard heart failure therapy if left ventricular dysfunction is present. Regular follow-up with serial echocardiography and cardiac MRI is essential to monitor recovery, as recommended in the 2015 ESC guidelines 1. Most cases resolve with appropriate treatment, though some patients may develop chronic pericarditis or dilated cardiomyopathy, necessitating long-term cardiac care.
From the Research
Investigation of Myopericarditis
- Myopericarditis is a primarily pericardial inflammatory syndrome occurring when clinical diagnostic criteria for pericarditis are satisfied and concurrent mild myocardial involvement is documented by elevation of biomarkers of myocardial damage (i.e., increased troponins) 2.
- Echocardiography and cardiac magnetic resonance imaging are important tools in the evaluation of myopericarditis, as the diagnosis of left ventricular dysfunction greatly affects the management, follow-up, and prognosis of these patients 3.
- The clinical presentation of myopericarditis is often with varying degrees of cardiac symptomatology, and its etiology is often idiopathic, but it may also be related to infectious and inflammatory prodrome 3.
Management of Myopericarditis
- Management is similar to that reported for pericarditis, generally with a reduction of empiric anti-inflammatory doses mainly aimed at the control of symptoms 2.
- Rest and avoidance of physical activity beyond normal sedentary activities has been recommended for 6 months, as for myocarditis 2.
- The use of NSAIDs is often cautioned, as it has been described to actually accelerate the myocarditic process in animal models, possibly increasing mortality 3, 4.
- Colchicine, a well-established anti-inflammatory agent, may have a role in the management of acute myopericarditis 3, 5, 6.
- Routine use of colchicine for the initial management of myopericarditis as a first-line adjunct therapy to aspirin/NSAIDs in patients with myopericarditis has favorable effects on electrocardiographic indices of atrial activation parameters 6.
Prognosis of Myopericarditis
- Usually complete remission is seen in 3-6 months 2.
- On follow-up, the majority of these cases had objective normalization of echocardiography, electrocardiography, laboratory testing, and functional status, although up to 14% may report atypical, non-limiting chest discomfort 4.
- At present, there is no evidence that troponin elevation confers worse prognosis (i.e., a greater risk of recurrence, death or transplantation) in patients with preserved left ventricular function 2.