ST Elevation and a Positive Troponin: Is it Myopericarditis or STEMI?

In this study of 625 patients with presumed STEMI who had angiograms within 2 hours of the ECG, but not simultaneous with the ECG, 26 had completely normal angiograms. The final clinical diagnosis by 3 cardiologists (not by MRI or biopsy) was STEMI in 7 (1.2%) and myopericarditis in 5 (0.8%).  Normal angiograms (no stenosis at all) seem to occur in about 4.5% of patients with Non-STE-ACS, but they still have substantial subsequent morbidity (2% death or MI at 1 year; TIMI score stratifies them well)Finally, there is this paper by Sarda et al. from JACC in which they studied 45 patients with apparent STEMI but with normal coronary arteries.  They used Indium scintigraphy to assess whether it was MI or myocarditis.  In 35 of 37 cases with adequate followup, it was myocarditis.  In 2, it was MI.  However, this article states that scintigraphy has poor sensitivity and specificity for myocarditis: "Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases."Was the initial management correct?  Yes.  This could have been STEMI and should be managed as such.  It still might have been STEMI.  The ST depression in V1 and V2 is particularly worrisome.  Had it been possible to get a high quality echocardiogram at the time of the ST elevation, and it had been completely normal, then it ...
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