Differentiation between myopericarditis and acute myocardial infarction on presentation in the emergency department using the admission C-reactive protein to troponin ratio

Abstract

Background The treatment of myopericarditis is different than that of acute myocardial infarction (AMI). However, since their clinical presentation is frequently similar it may be difficult to distinguish between these entities despite a disparate underlying pathogenesis. Myopericarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We hypothesized that evaluation of the CRP/troponin ratio on presentation to the emergency department could improve the differentiation between these two related clinical entities whose therapy is different. Such differentiation should facilitate triage to appropriate and expeditious therapy. Methods We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large single center registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed on discharge as myopericarditis. CRP and troponin were sampled on admission in all patients and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of myopericarditis against all AMI, STEMI, and NSTEMI patients. Results Median admission CRP/troponin ratios were 84, 65, and 436 mg×ml/liter×ng in STEMI, NSTEMI and myopericarditis groups, respectively (p<0.001) demonstrating good differentiating capability. The Receiver-operator-curve of admission CRP/troponin ratio for diagnosis of myopericarditis against all AMI, STEMI, and NSTEMI patients yielded an area-under-the curve of 0.74, 0.73, and 0.765, respectively. CRP/troponin ratio>500 resulted in specificity exceeding 85%, and for a ratio>1000, specificity>92%. Conclusion The CRP/troponin ratio can serve as an effective tool to differentiate between myopericarditis and AMI. In the appropriate clinical context, the CRP/troponin ratio may preclude further evaluation.

A rare case of COVID-19 vaccine-induced myopericarditis in a young adult

“…In one study, the CRP to troponin ratio of more than 250 was determined to have a specificity of more than 85% in differentiating myopericarditis from acute myocardial infarction. This further emphasizes the validity of myopericarditis as the final diagnosis considering the CRP/Troponin value for this patient was approximately 430 [8] .…”

Case Report: Myopericarditis in 19 Years Old Male

“…7 The electrocardiogram (ECG) may indicate ischemic alterations or even imitate an ST-segment elevation myocardial infarction in cases of myopericarditis, which can resemble AMI and present promptly with typical ischemic symptoms (STEMI). 8 Acute pericarditis was discovered to be a substantial cause of cardiovascular hospitalizations in 1.7% of patients with ST-segment elevation in those in whom myocardial infarction had been ruled out. 4,9 In general, males had a higher chance of having pericarditis than women do, and when age increased by a decade, the number of pericarditisrelated hospital admissions fell by an estimated 51%.. 9 In our case, the patient complaining pleuritic chest pain and diffuse ST elevation from the ECG which met 2 of 4 diagnostic criteria for acute pericarditis according to European Society of Cardiology (ESC).…”

Cardiac troponins: Mechanisms of release and role in healthy and diseased subjects

“…Similar to AMI patients, myopericarditis patients can have at admission acute chest pain, electrocardiographic changes and elevated cTns levels, making complicated the distinction between myopericarditis and AMI 62 . In a very recent study, Meisel et al suggested the use of CRP/troponin ratio as a tool to differentiate among AMI and myopericarditis patients 62 . Considering that the myopericarditis is an inflammatory disease, a CRP/troponin ratio > 250 “could indicate” the presence of myopericarditis, while a CRP/troponin ratio > 500 “could confirm the diagnosis” of a cardiac inflammatory condition in patients presenting with an acute cardiac syndrome when the clinical circumstances suggest low pre‐test probability of obstructive coronary artery disease 62 …”

“…107 The use of several techniques for protein analysis allowed to understand that cTnI and cTnT can be found in the blood either as cTns complex, as intact proteins, or degradation protein products. 62 By the use of western blot analysis, Madsen et al observed in a group of 26 male patients with acute STEMI, treated with thrombolytic drugs, that intact cTnI and a single degradation product (24 and 20 kDa, respectively) were detectable as early as 90 min after onset of symptoms with further degradation (up to 7 degradation products) after 165 min. 109 Cardinaels et al employed gel filtration chromatography (GFC) and western blot analysis to establish which cTnT forms circulate in the blood of AMI patients.…”

“…Myopericarditis is more prevalent in pediatric patients compared to adults 61 . Similar to AMI patients, myopericarditis patients can have at admission acute chest pain, electrocardiographic changes and elevated cTns levels, making complicated the distinction between myopericarditis and AMI 62 . In a very recent study, Meisel et al suggested the use of CRP/troponin ratio as a tool to differentiate among AMI and myopericarditis patients 62 .…”