Noble Medical and Diagnostics

5 points to remember about myocarditis in the ER

1.     Variable presentation, high index of suspicion: Myocarditis can present with a wide range of symptoms, from mild chest pain, fatigue, and shortness of breath to acute heart failure, arrhythmias, or sudden cardiac death. It often mimics acute coronary syndrome. Consider in younger patients with recent viral illness.

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2.     Diagnostic Clues: An abnormal ECG (look for diffuse ST elevation, non specific ST changes, arrhythmias), elevated cardiac biomarkers (troponin, BNP), and abnormal bedside ultrasound (regional wall motion abnormalities, LV dysfunction). Formal echocardiogram, Cardiac MRI and cardiac biopsy are often necessary for confirmation of the diagnosis.

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3.     Common Causes: Viral infections (e.g., enteroviruses) are the most frequent triggers. Others include drugs, autoimmunes, hypersensitivity reactions. Rare but important causes are giant cell myocarditis, eosinophilic myocarditis and sarcoidosis. Post-vaccine myocarditis (e.g., mRNA COVID-19 vaccines) has also gained attention, typically mild and self-limiting.

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4.     Management Priorities: Focus on supportive care—stabilize hemodynamics, manage arrhythmias, and treat heart failure if present. NSAIDs may help with pericarditis overlap, but avoid in fulminant cases. Occasional patients may need advanced therapies like prompt immunosuppression (giant cell myocarditis), ECMO, ventricular assist devices or even transplant.

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5.     Red Flags: Fulminant myocarditis can progress rapidly. Watch for signs of deterioration, such as heart failure or high-grade conduction disease on ECG. Many patients with suspected mild myocarditis can be discharged with close outpatient follow-up. Physical activity should be restricted during the acute phase of myocarditis.