Acute Myopericardial Syndrome: A Guide for Resident Doctors in the ED

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What Is Acute Myopericardial Syndrome?

It’s a clinical term for a presentation that has features of both pericarditis (inflammation of the pericardium) and myocarditis(inflammation of the heart muscle), often viral in origin.

Think of it as a continuum:

• Pericarditis → Myopericarditis → Myocarditis

When the myocardium is involved (↑ troponin), the term myopericarditis is used.

History Taking: Ask with Intention

Your first job is to distinguish myopericardial syndrome from more sinister causes of chest pain (like ACS, PE, aortic dissection). Here’s what you should ask:

Presenting Symptoms

Question	Why It Matters
"Can you describe the chest pain?"	Classically sharp, pleuritic, retrosternal, worse when lying flat, better when leaning forward.
"When did it start?"	Viral prodrome may precede onset by a few days.
"Have you had a recent infection?"	Viral illness often precedes it. Look for flu-like symptoms.
"Does anything make the pain better or worse?"	Positional and pleuritic features suggest pericardial inflammation.
"Do you get palpitations or breathlessness?"	Could indicate myocardial involvement (i.e. myocarditis).
"Any leg swelling, dizziness, or syncope?"	Look for signs of heart failure or arrhythmias.
"Any past medical history, recent travel, vaccines, or autoimmune disease?"	TB, HIV, SLE, and other infections/autoimmune causes possible.

Examination: Look, Listen, Lean

Be thorough. Your findings may be subtle or even absent.

General Observation

• Tachycardia (compensation or inflammation)

• Fever (infectious cause)

• Diaphoresis or pallor (think again: ACS?)

Cardiovascular Exam

Finding	What It Suggests
Pericardial rub (scratchy sound)	Pericarditis hallmark
Distant heart sounds	Possible pericardial effusion
Elevated JVP, hypotension, muffled heart sounds	Beck’s triad → think tamponade
Irregular rhythm	Atrial arrhythmias due to myocardial irritation

Respiratory Exam

• Pleural rub or basal creps (rule out pneumonia or pulmonary embolism)

Investigations: Follow the Evidence

Your goal is to rule out red flags, confirm the diagnosis, and assess severity.

Blood Tests

Test	Why It Matters
Troponin	Often mildly raised in myopericarditis. Significantly raised in myocarditis.
FBC	Leucocytosis may suggest viral or bacterial infection.
CRP/ESR	Raised in inflammation. Helps track treatment response.
U&E, LFTs	Check organ function before NSAIDs or colchicine.
Blood cultures	If febrile or septic.
Autoimmune screen (ANA, RF, dsDNA)	If suspect autoimmune cause
Viral serologies (e.g. Coxsackie, HIV)	Not always helpful acutely, but consider if immunocompromised.

ECG: The Four Stages of Pericarditis

• Stage I: Widespread concave ST elevation + PR depression

• Stage II: ST segments normalize

• Stage III: T wave inversion

• Stage IV: ECG returns to baseline

🩻 Chest X-ray

• Usually normal

• May show cardiomegaly if there’s a large effusion

🫀 Echocardiogram

• Rule out tamponade

• Look for pericardial effusion or reduced ejection fraction

🧲 Cardiac MRI (if available)

• Gold standard to diagnose myocarditis

• Shows myocardial oedema and late gadolinium enhancement

Management Plan: Treat the Inflammation, Monitor the Muscle

General Advice

• Reassure: most viral myopericarditis cases are self-limiting

• Advise rest and avoidance of strenuous activity for several weeks

Medications

Drug	Use	Notes
NSAIDs (e.g. ibuprofen)	First-line	Reduces pain and inflammation
Colchicine	Add to NSAIDs	Reduces recurrence rate
PPI	With NSAIDs	Protects GI tract
Avoid corticosteroids	Unless autoimmune cause	Risk of recurrence

If myocarditis is prominent (↓ EF or arrhythmias):

• Admit

• Consider heart failure treatment (ACEi, beta-blockers)

• Monitor for arrhythmias

What to Avoid

• Anticoagulation: Unless another indication (e.g. AF)

• Strenuous exercise: Can precipitate arrhythmias in myocarditis

When to Admit?

• Troponin significantly raised

• ECG changes suggest myocarditis

• Arrhythmias

• Hypotension or tamponade signs

• Immunocompromised or unclear cause

Follow-Up

• Arrange cardiology or medical follow-up

• Echo in 1–2 weeks if effusion or myocarditis

• Advice on return to exercise: only after full symptom resolution, normalized troponin, and cardiac function reassessed

Key Takeaways for the Resident Doctor

• Think myopericardial syndrome in young patients with sharp, positional chest pain and normal coronaries.

• Don’t dismiss elevated troponin as ACS—check the full clinical picture and ECG.

• NSAIDs + colchicine is your go-to unless myocarditis dominates.

• Echo is your friend. Don’t miss tamponade.

• Know when to admit and when to safely discharge.