What is the primary treatment for a patient with myopericarditis?

Treatment of Myopericarditis

Immediate Management

All patients with myopericarditis must be hospitalized for monitoring, exclusion of acute coronary syndrome, and surveillance for complications. 1

• Coronary angiography should be performed based on clinical presentation and risk factors to definitively rule out acute coronary syndrome 2, 1
• Cardiac magnetic resonance imaging is recommended to confirm myocardial involvement and exclude ischemic myocardial necrosis 2, 1

Anti-Inflammatory Therapy

The cornerstone of treatment is empirical anti-inflammatory therapy at the lowest effective doses to control chest pain, not the full doses used in pure pericarditis. 1

First-Line Options:

• Ibuprofen 1200-2400 mg/day (600 mg every 8 hours) is the preferred NSAID due to its superior safety profile 1
• Aspirin 1500-3000 mg/day (divided every 8 hours) is an alternative first-line option 2, 1
• Indomethacin 75-150 mg/day (25-50 mg every 8 hours) should be avoided in elderly patients due to reduced coronary flow 1

Critical Dosing Distinction:

The European Society of Cardiology specifically recommends reduced dosages compared to pure pericarditis because animal models demonstrate that NSAIDs may enhance myocardial inflammation and increase mortality in pure myocarditis. 2, 1 While the applicability of these animal findings to humans remains questionable, the guideline errs on the side of caution. 2

Colchicine Controversy:

There is insufficient evidence to recommend colchicine in myopericarditis, despite its well-established benefit in pure pericarditis. 2, 1 This represents a key difference from pericarditis management where colchicine is standard adjunctive therapy.

Second-Line Therapy:

• Corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be reserved only for cases with contraindication, intolerance, or failure of aspirin/NSAIDs 2, 1
• Corticosteroids are not first-line treatment 1

Mandatory Activity Restriction

Absolute rest and avoidance of physical activity beyond normal sedentary activities is mandatory for a minimum of 6 months from disease onset. 2, 1, 3

• This restriction applies regardless of symptomatic improvement 1
• Sudden cardiac death has been reported in military personnel and athletes (particularly football/soccer players and swimmers) after strenuous exertion, even without prodromic symptoms 2
• This 6-month restriction is substantially longer than the 3-month restriction for athletes with pure pericarditis 2

Prognosis

Myopericarditis has an excellent prognosis with no evolution to heart failure or mortality in observational series. 2, 1

• Complete remission is typically seen in 3-6 months 3
• Troponin elevation does not confer worse prognosis in patients with preserved left ventricular function 3

Common Pitfalls to Avoid

• Do not use full NSAID doses as in pure pericarditis—use the lowest effective doses due to theoretical concerns from animal models 1
• Do not allow early return to exercise—the 6-month restriction is mandatory regardless of symptomatic improvement 1
• Do not assume colchicine has the same benefit as in pericarditis—there is insufficient evidence in myopericarditis 2, 1
• Do not use corticosteroids as first-line treatment—reserve for specific cases of contraindication, intolerance, or failure 1
• Do not discharge patients for outpatient management—hospitalization is mandatory for all cases 1