The differentiation between perimyocarditis and myopericarditis plays a role in diagnosis, since myocarditis requires endomyocardial biopsy with histologic evidence to establish the diagnosis. In contrast, pericarditis that is uncomplicated is not an indication for EMB. (Pinger 2019).
Auscultation
- Pulse-synchronous systolic-diastolic, creaking, near-auricular sound, most evident over the lingula near the sternum (so-called pericardial rubbing).
- Pericardial rubbing may sometimes be present only passively
- intensifies during inspiration (not obligatory; occurs in about 1/3 of patients [Franke 1984])
- no change of sound during respiratory pause (in contrast to pleural rubbing)
- absence of pericardial rubbing, however, does not exclude pericarditis.
(Kühl 2004)
Laboratory
- Slight increase in CK (Herold 2018); occurs in approximately 7.6% of patients
- Troponin rises in 32% of patients (Pinger 2019).
When inflammatory processes spread to the myocardium - in addition to typical inflammatory markers such as ESR acceleration, leukocytosis, elevation of C-reactive protein, etc.) may be elevated:
( (Erdmann 2009)
ECG
The ECG need not be fundamentally altered by pericarditis per se. Rather, the outer layer damage that usually exists in all or several leads results from inflammation of the adjacent myocardial layers (Herold 2018).
In myopericarditis, therefore, monophasic elevations of the ST segment are sometimes found. These may be diffusely distributed or localized, depending on the extent of the affected myocardial components.
The arrhythmias that sometimes occur include both supraventricular and ventricular ectopic beats or timed ventricular arrhythmias (Yugandhar 2018).
Arrhythmias are always indicative of myocardial involvement (Kühl 2004).
Echocardiography
Echocardiography should be performed routinely in cases of v. a. myopericarditis or perimyocarditis. Depending on the severity of the disease, a more or less large pericardial effusion is seen, the hemodynamics of which can be well assessed by echocardiography. Some authors describe a brightness of the pericardium in the presence of pericarditis. However, this represents only a nonspecific finding with limited specificity (Yugandhar 2018).
Occasionally, echocardiography demonstrates left ventricular dysfunction. These patients predominantly present with a more severe course and should be monitored more closely (Yugandhar 2018)
Chest X-ray
In milder forms of the disease, chest x-ray is usually unremarkable. In more severe courses, an enlarged cardiac silhouette is seen due to fluid accumulation in the pericardium (Yugandhar 2018).
Cardiac MRI.
MRI represents an important noninvasive type of examination (Imazio 2008).
With this, it is possible to determine the degree of pericardial and myocardial involvement. A midmyocardial to subepicardial diffuse patchy "late enhancement" is found as a sign of inflammation of the myocardium and a signal enhancement in the T2-weighted sequences as an expression of edema (Ludwig 2008).
Cardio- MRI can also be used - without invasive measures - to delineate the differential diagnosis of CAD (Yugandhar 2018). This is possible, for example, by dobutamine stress MRI and stress perfusion MRI (Laufs 2016) .
Coronary angiography
Coronary angiography is not generally indicated in patients with typical features of myopericarditis.
In patients with risk factors for atherosclerotic cardiovascular disease and in patients with known coronary artery disease, myocardial ischemia sometimes cannot be excluded by noninvasive examinations. In these patients, coronary angiography is recommended (Yugandhar 2018).
Endomyocardial biopsy
Endomyocardial biopsy, both in the case of untargeted puncture and MRI-guided puncture from the area of late enhancement, is of limited value because it is subject to the so-called "sampling error" (i.e., biopsies are taken from areas that are not affected by inflammation and thus yield a false-negative result[Ludwig 2008]).
However, biopsy should still be performed in patients who experience persistent deterioration under standard treatment, thereby allowing the diagnosis and therapy to be revised if necessary (e.g., sarcoidosis, giant cell myocarditis [Yugandhar 2018]).
However, the so-called Dallas criteria, the 1987 criteria for histopathological diagnosis of myocarditis due to lymphocyte infiltrate with necrosis of myocytes, are not present in 80%- 90% of cases with classic symptoms (Kasper 2015).