Myocarditis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]

Overview

Myocarditis must be differentiated from other causes of chest pain such as ST elevation myocardial infarction, pericarditis, and unstable angina. Myocarditis must also be differentiated from pulmonary edema and alcoholic cardiomyopathy.

Differential Diagnosis

Differential Diagnosis	History and Symptoms	Physical Examination	Laboratory Findings	Imaging Findings
ST Segment Elevation Myocardial Infarction	Chest pain with possible radiation to left arm and lower jaw Squeezing, crushing chest pain Sweating Nausea and vomiting	Anxious patient in pain with diaphoresis Signs of heart failure may be present Arrhythmia	ST elevation, new left bundle branch block, and Q wave on EKG Elevated cardiac biomarkers	Either complete or subtotal occlusion of an epicardial coronary artery on coronary angiography Confluent hyperenhancement extending from the endocardium
Non ST Elevation Myocardial Infarction	Crushing, left-sided substernal chest pain or pressure that radiates to the neck or left arm	Same as ST-elevation MI	ST-segment depression or T-wave inversion on EKG Elevated cardiac biomarkers
Pericarditis	Chest pain relieved by sitting up and leaning forward and worsened by lying down Fever, anxiety, difficulty breathing	Pericardial friction rub Signs of cardiac tamponade may be present	PR segment depression and electrical alternans on EKG	A flask-shaped, enlarged cardiac silhouette on CXR Pericardial thickness of more than 4 mm on MRI Pericardial effusion and cardiac chamber indentation or collapse on echo when cardiac tamponade is present
Pulmonary Edema	Hemoptysis Difficulty breathing, wheezing Symptoms of fluid overload if pulmonary edema is chronic	Dyspnea, nasal flaring End-inspiratory crackles Third heart sound (S3)	Low oxygen saturation on ABG	Kerley B lines, increased vascular markings, interstitial edema, and peribronchial cuffing on CXR Patchy alveolar infiltrates on CXR in noncardiogenic edema
Alcoholic Cardiomyopathy	Middle-aged man with history of alcohol abuse and shortness of breath on activity Fatigue, weakness, anorexia, and palpitations Leg swelling and pedal edema
Unstable Angina	Chest pain at rest

Differentiating Myocarditis from ST Segment Elevation Myocardial Infarction

Both diseases present with chest pain, elevated cardiac biomarkers, and focal left ventricular dysfunction. There are two studies that can be used to distinguish the two syndromes:

Coronary Angiography

Coronary angiography can be performed to distinguish myocarditis from ST segment elevation myocardial infarction. ST segment elevation myocardial infarction is associated with either complete or subtotal occlusion of an epicardial coronary artery on coronary angiography. When used in conjunction with the findings on coronary angiography, cardiac MRI is useful in establishing the diagnosis of myocarditis.

Cardiac Magnetic Resonance Imaging

Cardiac magnetic resonance imaging is also useful in distinguishing between the two diseases as well. On cardiac MRI, myocarditis is associated with patchy, non-sentimental, hyperenhancement which is confined to the epicardial layer of the myocardium. In contrast, in ST segment elevation myocardial infarction there is confluent hyperenhancement extending from the endocardium in a distribution that mimics the distribution of the epicardial coronary arteries.

Differentiating Myocarditis from Pericarditis

Both diseases present with chest pain and ST segment elevation. The two conditions can be distinguished by the following studies:

Electrocardiogram

While both disorders are associated with ST segment elevation, pericarditis is also associated with PR segment depression.

Cardiac Biomarkers

Myocarditis is associated with elevations of the CK-MB and the troponin, while pericarditis is not. If pericarditis is associated with underlying inflammation of the myocardium, then this is called myopericarditis. If there is concomitant involvement of both the pericardium and myocardium in myopericarditis, then there are elevations of the cardiac biomarkers.

Echocardiography

In patients with myocarditis there will be a focal wall motion abnormalities, while these will be absent in patients with pericarditis. There may be a pericardial effusion in the patient with pericarditis, while myocarditis is not associated with a pericardial effusion.