What are the next steps in evaluation and management of a patient with chest pain, sore throat, concern for pericarditis on electrocardiogram (EKG), and elevated troponin levels?

Immediate Evaluation and Risk Stratification

This patient requires hospital admission and urgent echocardiography to assess for myopericarditis, followed by risk stratification to determine need for advanced imaging and to exclude acute coronary syndrome. The combination of chest pain, EKG changes concerning for pericarditis, and elevated troponin defines myopericarditis rather than isolated pericarditis, which fundamentally changes management and prognosis 1, 2.

Initial Diagnostic Workup

Obtain these tests immediately:

• Transthoracic echocardiography (TTE) to assess for pericardial effusion (size and hemodynamic significance), ventricular wall motion abnormalities, left ventricular systolic function, and signs of tamponade physiology 1. Normal echocardiography does not exclude pericarditis, as effusion is present in only 60% of cases 2.

• Inflammatory markers including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count to confirm inflammation and establish baseline for monitoring treatment response 1.

• Serial troponin measurements at 3-6 hour intervals to establish rising/falling pattern characteristic of acute injury versus chronic elevation 3. Troponin elevation in this context indicates myocardial involvement and defines myopericarditis 2.

• Chest X-ray to evaluate for pleuro-pulmonary disease, though it will be normal unless pericardial effusion exceeds 300 mL 1.

Critical Risk Stratification for Admission Decision

This patient requires hospital admission based on the following high-risk features:

The presence of elevated troponin itself is a minor risk factor mandating admission 1. Additional major risk factors to assess include:

• Fever >38°C (>100.4°F) 1
• Subacute course (symptoms developing over several days without clear acute onset) 1
• Large pericardial effusion (diastolic echo-free space >20 mm) 1
• Cardiac tamponade 1
• Failure to respond to NSAIDs within 7 days (assessed on follow-up) 1

The sore throat preceding chest pain suggests a viral prodrome, which is the most common etiology in developed nations 1.

Distinguishing Myopericarditis from Acute Coronary Syndrome

Key differentiating features to assess:

• Chest pain character: Pericarditic pain is typically sharp, pleuritic, and improves with sitting up or leaning forward, though these classic features may be absent 1, 2. Pain lasting >20 minutes unrelated to position changes suggests type 1 MI 4.

• EKG patterns: Widespread ST-elevation with PR depression is the hallmark of pericarditis, present in up to 60% of cases 1. Focal ST-elevation or ST-depression >1 mm suggests acute coronary syndrome requiring different management 1, 4, 5.

• Physical examination: Listen for pericardial friction rub, though absence does not exclude pericarditis 1.

• Echocardiographic findings: Regional wall motion abnormalities suggest myocardial infarction or significant myocarditis, whereas global hypokinesis or normal function with pericardial effusion supports myopericarditis 1, 2, 6.

Advanced Imaging: Cardiac MRI

Cardiac MRI with gadolinium contrast is indicated when:

• Diagnostic uncertainty exists between myopericarditis and acute coronary syndrome 1, 2
• Determining extent of myocardial and pericardial inflammation 1, 2
• Distinguishing from MINOCA (myocardial infarction with nonobstructive coronary arteries) 1

CMR has 94-100% sensitivity for detecting pericardial inflammation and should be performed within 2 weeks of presentation for optimal diagnostic yield 1, 2. CMR findings include pericardial enhancement, thickening, increased T2 signal indicating edema, and late gadolinium enhancement patterns that distinguish myopericarditis from ischemic injury 1.

Management Algorithm

For patients with confirmed myopericarditis (pericarditis + elevated troponin):

1. Hospital admission for continuous telemetry monitoring 1

2. Anti-inflammatory therapy with NSAIDs (ibuprofen 600-800 mg three times daily or aspirin 750-1000 mg three times daily) plus colchicine 0.5 mg twice daily 1

3. Avoid anticoagulation unless clear evidence of type 1 MI exists, as this worsens outcomes 4

4. Serial troponin and inflammatory markers to monitor disease activity 1, 3

5. Follow-up assessment at 1 week to evaluate response to anti-inflammatory therapy 1

6. Cardiac MRI if diagnostic uncertainty persists or to assess extent of myocardial involvement 1, 2

Critical Pitfalls to Avoid

Do not pursue urgent cardiac catheterization reflexively for troponin elevation in the setting of suspected myopericarditis with typical EKG changes and no focal ischemic features 4, 6, 5. This delays appropriate anti-inflammatory treatment and exposes patients to unnecessary anticoagulation risks 4.

Do not dismiss elevated troponin as benign even though minimally elevated troponin in pericarditis does not confer worse short-term prognosis 1, 2. The presence of troponin elevation defines myopericarditis and requires hospital admission and monitoring, as sudden cardiac death can occur even without traditional high-risk features 7.

Do not assume normal echocardiography excludes significant disease 2. Proceed with cardiac MRI if clinical suspicion remains high despite normal TTE 1, 2.

Prognosis and Follow-up

Elevated troponin in myopericarditis identifies a subgroup with reduced risk of recurrences compared to isolated pericarditis (4% vs 17%) 8. However, cardiac mortality may be higher in myopericarditis despite absence of clinical heart failure 9. Subacute presentation and failure to respond to NSAIDs within 7 days predict adverse outcomes including tamponade, constriction, and recurrence 1, 8.