Correspondence

Acute Myocarditis Masquerading as Acute Myocardial Infarction

N Engl J Med 1993; 328:1714-1715June 10, 1993

Article

To the Editor:

The Brief Report by Narula et al. (Jan. 14 issue)1 highlights the frequency with which myocarditis masquerades as myocardial infarction. While we were performing a meta-analysis of patients with myocarditis presenting as myocardial infarction, we noted that there seemed to be similarities between Patients 2 through 4 and Patient 8 of Narula et al. and patients described by Dec et al.2. We would appreciate a clarification, to prevent duplication of patients in our meta-analysis.

D.A.N. Mascarenhas, M.B., B.S., M.D.
University of Massachusetts School of Medicine, Worcester, MA 01655

David H. Spodick, M.D., D.Sc.
St. Vincent Hospital, Worcester, MA 01604

2 References

1. 1

   Narula J, Khaw BA, Dec GW Jr, et al. Recognition of acute myocarditis masquerading as acute myocardial infarction. N Engl J Med 1993;328:100-104
   Full Text | Web of Science | Medline

2. 2

   Dec GW Jr, Waldman H, Southern JF, Fallon JT, Hutter AM Jr, Palacios I. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol 1992;20:85-89
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Drs. Mascarenhas and Spodick have correctly surmised that a subgroup of the patients described in our article was also described in an earlier study from our institution1. Patients 1 through 4 and Patient 8 were included in both series.

The initial report by Dec et al.1 described the clinical presentation, electrocardiographic evolution, abnormalities of ventricular function, and subsequent outcome in the first 11 patients who presented with this syndrome. This study population was drawn from a data base of all patients with suspected infarction and normal coronary arteries according to angiography. As we pointed out in the original report, this group contains only a tiny minority of the patients admitted each year with suspected acute myocardial infarction.

Therefore, the first study demonstrated that myocarditis can present as acute myocardial infarction and recommended performing right ventricular biopsy to make the diagnosis1. The second study, reported in the Journal, was designed to address the utility of antimyosin scintigraphy as a diagnostic approach to differentiate patients with myocarditis from those with acute myocardial infarction. In addition, this study compared the patterns of antimyosin uptake seen in both conditions. All patients from this study were identified from an independent list of patients who had undergone antimyosin imaging for suspected myocarditis.

Findings from this study suggest a role for antimyosin scintigraphy in patients in whom infarction has been excluded. The pattern of antimyosin uptake may be particularly useful for screening before biopsy. Since the myocyte necrosis seen in myocarditis is typically multifocal and results in diffuse rather than segmental uptake of antimyosin, a scan showing diffuse uptake provides additional, supportive evidence of a primary myopathic rather than ischemic process. Patients with negative scans are extremely unlikely to have either myocarditis2 or acute myocardial infarction3.

The series of cases reported in the Journal extends our original observations regarding this unusual manifestation of myocarditis and suggests a role for noninvasive assessment of possible myocarditis in patients whose coronary anatomy is demonstrated to be normal.

G. William Dec, M.D.
Jagat Narula, M.D.
Tsunehiro Yasuda, M.D.
Massachusetts General Hospital, Boston, MA 02114

3 References

1. 1

   Dec GW Jr, Waldman H, Southern JF, Fallon JT, Hutter AM Jr, Palacios I. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol 1992;20:85-89
   CrossRef | Web of Science | Medline

2. 2

   Dec GW, Palacios I, Yasuda T, et al. Antimyosin antibody cardiac imaging: its role in the diagnosis of myocarditis. J Am Coll Cardiol 1990;16:97-104
   CrossRef | Web of Science | Medline

3. 3

   Berger H, Lahiri A, Leppo J, et al. Antimyosin imaging in patients with ischemic chest pain: initial results of Phase III Multicenter Trial. J Nucl Med 1988;29:805-806 abstract.
   

Citing Articles (2)

Citing Articles

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   Ing-Kit Lee, Wen-Huei Lee, Jien-Wei Liu, Kuender D. Yang. (2010) Acute myocarditis in dengue hemorrhagic fever: a case report and review of cardiac complications in dengue-affected patients. International Journal of Infectious Diseases 14:10, e919-e922
   CrossRef

2. 2

   S. Rodado Marina, V.M. Poblete García, A.M. García Vicente, S. Ruiz Solís, M.P. Talavera Rubio, M. Cortés Romera, A. Soriano Castrejón. (2006) SPECT de perfusión miocárdica con 99mTc-Tetrofosmin y SPECT torácica con Galio-67 en paciente con dolor torácico y antecedente de sarcoidosis. Revista Española de Medicina Nuclear 25:1, 35-39
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