Perimyocarditis
A 35 yo patient presents with sharp central chest pain, that he has had since yesterday and has become worst.
The pain does not radiate and improves when he sits up.
He has no other symptoms and no other medical history.
Examination is essentially normal.
His ECG is shown below;
The pain does not radiate and improves when he sits up.
He has no other symptoms and no other medical history.
Examination is essentially normal.
His ECG is shown below;
What does the ECG show?
ANSWER
There are changes consistent with pericarditis. (go to the section on pericarditis)
There is widespread ST elevation, with the ST elevation in III being less than in II
There is also PR depression and no reciprocal changes, although there is T wave inversion in aVL.
There is widespread ST elevation, with the ST elevation in III being less than in II
There is also PR depression and no reciprocal changes, although there is T wave inversion in aVL.
The patient's troponin returns at 8000 ng/L (normal is <14ng/L)
Which of the following would you do in this 35 yo?:
(a) Activate the Cath lab, or if you don't have one transfer to a Cath lab equiped hospital
(b) Thrombolyse if no Cath lab
(c) Get an ECHO
(d) Do a serial Troponin
An ECHO was performed and this was normal, ie., no pericardial effusion and no left ventricular involvement with normal ejection fraction.
Which of the following would you do in this 35 yo?:
(a) Activate the Cath lab, or if you don't have one transfer to a Cath lab equiped hospital
(b) Thrombolyse if no Cath lab
(c) Get an ECHO
(d) Do a serial Troponin
An ECHO was performed and this was normal, ie., no pericardial effusion and no left ventricular involvement with normal ejection fraction.
ANSWER
An ECHO was performed and this was normal, ie., no pericardial effusion and no left ventricular involvement with normal ejection fraction.
What is the diagnosis now?
We need to discuss the differences between Myopericarditis and Perimyocarditis
We need to discuss the differences between Myopericarditis and Perimyocarditis
Myopericarditis
This is pericarditis with myocardial involvement. The clinical presentation is similar to that of pericarditis and may include a pericardial rub, ST elevation on ECG and a pericardial effusion. When ECG changes are present (the evolution of which is variable), they indicate an inflammation of the epicardium as the pericardium is electrically inert.
In Myopericarditis the cardiac biomarkers are also elevated. However there is NO focal or diffuse impairment of the left ventricular function on ECHO or Cardiac MRI(CMR). CMR can confirm myocardial involvement and rule out ischaemic myocardial necrosis, in the absence of coronary artery disease. However a coronary angiogram may be needed.
Hospital admission is needed and treatment involves the same approach as in pericarditis ie NSAIDs and Colchicine.
restriction of exercise is recommended as there have been cases of sudden cardiac death during strenuous exercise.
In isolated pericarditis return to exercise is fine in normal circumstances, however in athletes a 3 month restriction may be required.
If there is any suspicion of myocardial involvement, then a 6 month restriction on exercise is required.
Myopericarditis has a good prognosis.
In Myopericarditis the cardiac biomarkers are also elevated. However there is NO focal or diffuse impairment of the left ventricular function on ECHO or Cardiac MRI(CMR). CMR can confirm myocardial involvement and rule out ischaemic myocardial necrosis, in the absence of coronary artery disease. However a coronary angiogram may be needed.
Hospital admission is needed and treatment involves the same approach as in pericarditis ie NSAIDs and Colchicine.
restriction of exercise is recommended as there have been cases of sudden cardiac death during strenuous exercise.
In isolated pericarditis return to exercise is fine in normal circumstances, however in athletes a 3 month restriction may be required.
If there is any suspicion of myocardial involvement, then a 6 month restriction on exercise is required.
Myopericarditis has a good prognosis.
Perimyocarditis
This is myocarditis with some pericardial involvement. In these patients there are:
- Clinical criteria of pericarditis PLUS
- Troponin rise PLUS
- New onset of focal or diffuse reduction in left ventricular function. These patient may require end-myocardial biopsy.