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 pericarditis and ST elevation myocardial infarction.

Differential Diagnosis

Differential Diagnosis	Clinical Findings	Imaging Findings
ST Segment Elevation Myocardial Infarction	Multiple foci of inflammation	Acute severe cardiovascular compromise with ventricular dysfunction
Pericarditis	IDH1 p53 Gene on chromosome 10q Gene on chromosome 17p Gene on chromosome 19q
Pulmonary Edema	EGFR
Alcoholic Cardiomyopathy	TP53 PDGFRA IDH1
Unstable Angina	TP53 PDGFRA IDH1

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.