Differentiating COVID-associated myocarditis from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Overview

COVID-19-associated myocarditis must be differentiated from other causes of dyspnea and chest pain, elevated cardiac biomarkers, ventricular dysfunction such as including Acute Coronary Syndrome, Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) and Heart failure.

Differential Diagnosis

COVID-19-associated myocarditis must be differentiated from other causes of dyspnea and chest pain, elevated cardiac biomarkers, ventricular dysfunction such as including Acute Coronary Syndrome, Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) and Heart failure.

Diseases	Symptoms			Physical Examination			Diagnostic tests				Other Findings
	Dyspnea on Exertion	Chest Pain	Hemoptysis	Fever	Tachypnea	Tachycardia	Chest X-ray	ECG	Echocardiography	CT scan and CMR
COVID-19-associated myocarditis	✔	✔	-	✔	✔	✔	Pericardial effusion may be detectable	Non-specific:may show nonspecific ST-T abnormalities, sinus tachycardia and conduction abnormalities (such as bundle-branch blocks or atrioventricular conduction delays)	Non-specific: In fulminant myocarditis, cardiac chamber sizes are usually normal with an increased septal thickness (secondary to acute myocardial edema), whereas in acute myocarditis marked left ventricular dilation and normal wall thickness might be seen. Pericardial effusion may be be seen.	CMR: T2-weighted edema imaging shows the presence of “acute myocardial inflammation”. "Late gadolinium enhancement (LGE) imaging” can demonstrate myocardial damage.	Increased cardiac troponins level
COVID-19-associated myocardial infarction	✔	✔	-	✔/-	✔/-	✔/-	No specific X-ray findings	ST elevation MI (STEMI) Non-ST elevation MI (NSTEMI) or Non Q wave	Localized wall motion abnormalities Diffuse hypokinesia Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.	-	Increased cardiac troponin levels
COVID-19-associated stress cardiomyopathy	✔	✔	-	-	✔	✔	Takotsubo-shaped heart, in which there is apical ballooning and narrowing of the proximal portion near the great vessels.	ST elevation in the precordial leads T wave inversion Q wave formation QT prolongation New-onset bundle branch block (BBB) Rarely, malignant ventricular arrhythmias may be seen	Apical ballooning Apical or mid-segment dyskinesia or akinesia Left ventricular systolic dysfunction Reduced ejection fraction	CT: Regional abnormalities in the wall motion of the heart, along with absence of coronary atherosclerosis. CMR: Absence of gadolinium hyper-enhancement; also shows absence of irreversible damage, regional wall abnormalities with extent and segmental LV dysfunction.	Increased cardiac troponin and pro-BNP level, transient increase in catecholamine levels.
COVID-19-associated heart failure	✔	-	✔	-	✔	✔	Cardiomegaly Pulmonary edema (interstitial, alveolar)	Left ventricular hypertrophy Low-voltage QRS Non-specific ST-T change	Systoloic dysfunction (in HFrEF) Diastoic dysfunction (in HFpEF) COVID-19-associated stress cardiomyopathy (apical ballooning)	CT: Cardiomegaly, Pulmonary edema CMR: Signs of underlying myocarditis may be seen.	Increased NT-proBNP and cardiac troponins levels
COVID-19-associated pneumonia	✔	✔ (Pleuritic)	✔	✔ (Usually high)	✔	✔	Lobar Consalidation	Prolonged PR interval Transient T wave inversions	-	CT: Lobar Consalidation	Increased inflammatory markers, including ESR, hs-CRP
COVID-19-associated acute respiratory distress syndrome	✔	-	✔	✔	✔	✔	Bilateral ground-glass opacities	-	Signs of RV dysfunction/RV dilatation may be seen.	CT: Bilateral ground-glass opacities	-
COVID-19-associated pulmonary embolism	✔ (Usually sudden-onset)	✔ (Pleauritic)	✔ (If massive PE)	✔ (Low-grade)	✔	✔	May show Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	Non-specific:may show S1Q3T3 pattern	May show signs of RV strain, Rv dilatation, Rv dysfunction (if large PE)	On CT angiography: Intra-luminal filling defect On MRI: Narrowing of involved vessel No contrast seen distal to obstruction Polo-mint sign (partial filling defect surrounded by contrast)	Increased D-dimer, fibrinogen, and fibrin degradation products levels May have symptoms and/or signs of accompanying DVT

References