Diagnosing and Treating Pericarditis and Myocarditis in the Emergency Department

Table of Contents

 

About This Issue

When a patient presents with chest pain and dyspnea, pericarditis and myocarditis should be on the differential. Diagnosing these diseases can be difficult, as gold-standard testing is not available in the ED, but because they can progress to serious cardiac diseases and shock, it is essential to initiate treatment and follow-up as soon as possible. In this issue you will learn:

How pericarditis and myocarditis differ in presentation, and the very different treatment strategies each requires.

What questions to ask: is there history of recent illness, travel, vaccination, or medication use?

The diagnostic criteria for pericarditis and myocarditis, and how they differ.

What tests are required: electrocardiogram, troponin, ESR, CRP?

Which imaging studies are highest yield: ultrasound, CT, or MRI?

When you should discharge a patient with pericarditis with NSAIDs, and which patients need to be admitted.

What the best treatments for myocarditis are, and when patients need to be admitted to the ICU.

What are the risks of COVID-19 infection versus mRNA vaccines?

When mechanical circulatory support and mechanical ventilation should be initiated.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Pericarditis
   2. Myocarditis
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Bedside Testing
    2. Laboratory Testing
    3. Imaging
    4. Other Testing
11. Treatment
    1. Pericarditis Treatment
    2. Myocarditis Treatment
    3. Managing Hemodynamic Instability
12. Special Populations
    1. COVID-19, Vaccines, and Myocarditis
    2. Multisystem Inflammatory Syndrome in Children
    3. Competitive Athletes
13. Controversies and Cutting Edge
14. Disposition
    1. Pericarditis
    2. Myocarditis
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls for Managing Pericarditis and Myocarditis in the Emergency Department
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Pericarditis
    2. Clinical Pathway for Emergency Department Management of Myocarditis
21. Tables and Figures
22. References

Abstract

Pericarditis and myocarditis represent a challenging set of diseases to diagnose and treat. These diseases typically present with chest pain and dyspnea in previously healthy young people, often in the weeks following a viral illness, including COVID-19. Nonetheless, the etiologies can be very diverse, including infectious, noninfectious, drug-induced, and autoimmune causes. This review focuses on the evaluation, diagnosis, and management of emergency department patients presenting with pericarditis and myocarditis and summarizes current guidelines and best-practice medical management strategies in order to avoid potential life-threatening cardiac complications.

Case Presentations

A 30-year-old man, who is otherwise healthy, presents with chest pain that has been present and progressive for the last 3 days…

• He reports having had a mild viral-like illness 1 week ago.
• The patient appears mildly volume-overloaded on examination, with a temperature of 38.1°C, heart rate of 105 beats/min, blood pressure of 125/74 mm Hg, and oxygen saturation of 98%.
• You suspect a viral syndrome but wonder whether a troponin and electrocardiogram are indicated...

A 22-year-old woman who was diagnosed with suspected myocarditis 1 month ago returns to the ED with a cough…

• She is well in appearance, with a normal chest x-ray and negative rapid viral testing today.
• Her temperature is 37°C; heart rate, 72 beats/min; blood pressure, 110/80 mm Hg; and oxygen saturation, 99%.
• She is a college athlete and says she would like to return to activity. She looks well, but you wonder whether she needs further testing and whether it is safe for her to return to sports...

EMS arrives with a 40-year-old man who suffered an out-of-hospital cardiac arrest…

• The patient was found to be in VTACH and was brought into the ED, now with return of spontaneous circulation following 2 defibrillations.
• EMS reports that the man’s family said he was otherwise healthy, aside from a recent viral illness.
• His temperature is 37°C; heart rate, 32 beats/min; blood pressure, 80/45 mm Hg; and oxygen saturation, 90%.
• He is poorly responsive, with a third-degree heart block and markedly reduced ejection fraction seen on bedside ultrasound.
• You wonder: why would such a young man have a cardiac arrest? What treatments should be initiated immediately, and what additional specialty services might this patient require?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Kytö V, Sipilä J, Rautava P. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation. 2014;130(18):1601-1606. (Retrospective cohort; 1361 patients) DOI: 10.1161/CIRCULATIONAHA.114.010376

2. * Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis. 2010;52(4):274-288. (Review) DOI: 10.1016/j.pcad.2009.11.006

4. * Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-2648. (Expert consensus) DOI: 10.1093/eurheartj/eht210

5. * Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Endorsed by: the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921-2964. (Expert consensus) DOI: 10.1093/eurheartj/ehv318

8. * Ammirati E, Cipriani M, Moro C, et al. Clinical presentation and outcome in a contemporary cohort of patients with acute myocarditis: Multicenter Lombardy Registry. Circulation. 2018;138(11):1088-1099. (Retrospective review; 443 patients) DOI: 10.1161/CIRCULATIONAHA.118.035319

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Keywords: pericarditis, myocarditis, COVID-19, chest pain, ACS, tachypnea, NSAID, ECMO, MIS-C, vaccine, athletes