Differentiating COVID-associated myocarditis from other Diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]


Overview

COVID-19-associated myocarditis must be differentiated from other causes of dyspnea and chest pain, elevated cardiac biomarkers, ventricular dysfunction such as including Acute Coronary Syndrome, Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) and Heart failure.

Differential Diagnosis

COVID-19-associated myocarditis must be differentiated from other causes of dyspnea and chest pain, elevated cardiac biomarkers, ventricular dysfunction such as including Acute Coronary Syndrome, Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) and Heart failure.

Diseases Symptoms Physical Examination Diagnostic tests Other Findings
Dyspnea on Exertion Chest Pain Hemoptysis Fever Tachypnea Tachycardia Chest X-ray ECG Echocardiography CT scan and CMR
COVID-19-associated myocarditis -
  • Non-specific: In fulminant myocarditis, cardiac chamber sizes are usually normal with an increased septal thickness (secondary to acute myocardial edema), whereas in acute myocarditis marked left ventricular dilation and normal wall thickness might be seen.
  • Pericardial effusion may be be seen.
  • CMR: T2-weighted edema imaging shows the presence of “acute myocardial inflammation”. "Late gadolinium enhancement (LGE) imaging” can demonstrate myocardial damage.
Increased cardiac troponins level
COVID-19-associated myocardial infarction - ✔/- ✔/- ✔/-
  • No specific X-ray findings
  • ST elevation MI (STEMI)
  • Non-ST elevation MI (NSTEMI) or Non Q wave
  • Localized wall motion abnormalities
  • Diffuse hypokinesia
  • Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.
  • -
Increased cardiac troponin levels
COVID-19-associated stress cardiomyopathy - -
  • CT: Regional abnormalities in the wall motion of the heart, along with absence of coronary atherosclerosis.
  • CMR: Absence of gadolinium hyper-enhancement; also shows absence of irreversible damage, regional wall abnormalities with extent and segmental LV dysfunction.
Increased cardiac troponin and pro-BNP level, transient increase in catecholamine levels.
COVID-19-associated heart failure - - Increased NT-proBNP and cardiac troponins levels
COVID-19-associated pneumonia ✔ (Pleuritic) ✔ (Usually high)
  • Prolonged PR interval
  • Transient T wave inversions
- Increased inflammatory markers, including ESR, hs-CRP
COVID-19-associated acute respiratory distress syndrome - -
  • Signs of RV dysfunction/RV dilatation may be seen.
-
COVID-19-associated pulmonary embolism ✔ (Usually sudden-onset) ✔ (Pleauritic) ✔ (If massive PE) ✔ (Low-grade)
  • Non-specific:may show S1Q3T3 pattern
  • May show signs of RV strain, Rv dilatation, Rv dysfunction (if large PE)
  • On CT angiography: Intra-luminal filling defect
  • On MRI: Narrowing of involved vessel
  • No contrast seen distal to obstruction
  • Polo-mint sign (partial filling defect surrounded by contrast)


References