From the Guidelines
Pericarditis is the more likely diagnosis given the patient's symptoms of sharp chest pain that improves when leaning forward, as this is a classic presentation of pericarditis, and the recent guideline from the American College of Cardiology/American Heart Association supports this diagnosis 1.
Clinical Presentation
The patient's symptoms of sharp chest pain that improves when leaning forward are consistent with pericarditis, as pericarditis typically presents with chest pain that is sharp, pleuritic, and which may be improved by sitting up or leaning forward 1. In contrast, myocarditis pain is usually not positionally relieved.
EKG Results
On ECG, pericarditis classically shows diffuse ST-segment elevation in multiple leads with PR depression, which is a key distinguishing feature from myocarditis 1. Myocarditis may show nonspecific ST-T wave changes, conduction abnormalities, or mimic a myocardial infarction pattern.
Troponin Levels
Troponin levels are typically elevated in myocarditis due to myocardial cell damage, whereas in pericarditis, troponins may be normal or only mildly elevated 1. A minimally elevated troponin does not appear to confer a worse prognosis in patients with pericarditis 1.
Management
The distinction between pericarditis and myocarditis matters because management differs - myocarditis often requires more aggressive monitoring for heart failure and arrhythmias, while pericarditis treatment focuses on anti-inflammatory medications like NSAIDs (ibuprofen 600mg three times daily or colchicine 0.6mg once or twice daily for 3 months) 1. Both conditions can occur simultaneously (myopericarditis), complicating the clinical picture.
Diagnostic Evaluation
Echocardiography is often needed to help distinguish between these conditions, with myocarditis showing wall motion abnormalities and pericarditis potentially showing pericardial effusion 1. A 12-lead ECG should be performed in all patients with clinically suspected myocarditis, and cardiac troponin levels are useful for diagnosis and should be obtained in patients with clinically suspected myocarditis 1.
From the Research
Myocarditis vs Pericarditis
- Myocarditis and pericarditis are two distinct conditions that affect the heart, with myocarditis being an inflammation of the heart muscle and pericarditis being an inflammation of the sac surrounding the heart 2.
- The symptoms of myocarditis and pericarditis can be similar, making diagnosis challenging, but leaning forward can be a symptom of pericarditis 3.
EKG Results
- Electrocardiogram (EKG) results can be helpful in diagnosing myocarditis and pericarditis, with myocarditis often showing signs of cardiac dysfunction and pericarditis showing signs of inflammation 4.
- EKG results can also be used to monitor the effectiveness of treatment and detect any potential complications 5.
Troponins
- Troponin levels can be elevated in both myocarditis and pericarditis, but are more commonly associated with myocarditis 5.
- Elevated troponin levels can indicate cardiac damage and are often used as a diagnostic tool for myocarditis 2.
Treatment
- Treatment for myocarditis and pericarditis differs, with myocarditis often requiring respiratory and hemodynamic support, and pericarditis often being treated with anti-inflammatory medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) [(3,5)].
- Colchicine has been shown to be effective in reducing the risk of recurrent pericarditis [(6,4)], but its use in myocarditis is not recommended due to potential deleterious effects 2.