Myocarditis with very high troponins: risk stratification by cardiac magnetic resonance

Myocarditis is an inflammation of the myocardium that can be caused by a variety of etiologies, commonly viral, but also toxins, drugs, and autoimmune processes (1). The usual patterns of clinical presentation include chest pain, arrhythmias, and heart failure. The disease severity may vary greatly, ranging from asymptomatic or mild flu-like symptoms to cardiogenic shock and sudden death (2). Patients presenting with chest pain with preserved left ventricular (LV) function typically have an excellent prognosis. Conversely, patients presenting with heart failure and/or life-threatening arrhythmias, in particular when associated with severe LV dysfunction, have a greater risk of adverse events during follow-up. An integrated approach with clinical evaluation (i.e., history, physical exam, electrocardiography) and noninvasive imaging [i.e., echocardiography, cardiac magnetic resonance (CMR) imaging] is fundamental for the identification of cases of suspected myocarditis. In patients with myocarditis presenting with chest pain, an acute coronary syndrome (ACS) often needs to be ruled out appropriately with an angiogram.