Elevated Cardiac Enzymes: Myocarditis, Heart Attack, or Cardiomyopathy?

Elevated myocardial enzymes could indicate myocarditis, myocardial infarction, or cardiomyopathy. The patient is 27 years old, 178 cm tall, weighs 63 kg, and is considered lean. Additionally, the patient has a history of hyperthyroidism?

Dear Dr.
He,
I apologize for the lengthy message.
On January 28 of this year, I went to the emergency room due to redness and swelling in both eyes, chest tightness, and a sore throat from a cold.
The emergency staff performed blood tests and an electrocardiogram (ECG), and the doctor said everything looked fine.
However, my initial blood test showed elevated Troponin I (84) and CK (65).
The second test showed Troponin I (291) and CK (192), the third test showed Troponin I (291) and CK (192), and the fourth test showed Troponin I (355) and CK (87), followed by Troponin I (276) and CK (72).
The doctor allowed me to go home after the fourth test showed a decrease in values (I was referred to a cardiologist, but the doctor only performed an ECG and then discharged me).
On February 1, I suddenly experienced chest tightness and my heart rate spiked to 150-160 beats per minute, with high blood pressure and difficulty breathing, prompting another visit to the emergency room.
Blood tests showed Troponin I (8) and CK (78), and the emergency doctor said these values were normal (they gave me NTG) and instructed me to return for outpatient care.
On February 25, I experienced sudden numbness in my limbs, chest tightness, and my heart rate increased rapidly, leading to another emergency visit where Troponin I (3) and CK (70) were also normal, and I was sent home again.
Afterward, I had blood tests at an external clinic, and my cholesterol and thyroid levels were normal.
An echocardiogram showed mitral valve prolapse, and tests for arterial sclerosis (in both arms and legs) were normal (on March 5).
On March 28, I experienced a similar episode with elevated heart rate and blood pressure, but the emergency values were normal again.
On April 3, I had another sudden episode (I used to smoke but have since quit).
From January to April, my heart rate has been consistently elevated, unlike before my symptoms began, and I have experienced chest tightness (I even ran 5-6 kilometers).
However, since the end of March, I have felt more fatigued and have had unusual chest tightness.
After the episode on April 3, my resting heart rate dropped to 50-60 beats per minute, sometimes as low as 48, with low blood pressure (high 90s over low 50s).
While sleeping, my heart rate dropped to 39-40, and while walking, it was 60-70 beats per minute, which is much lower than my normal levels (measured with an Apple Watch).
On April 13, I switched hospitals for a check-up, and on April 18, I suddenly experienced a rapid heart rate, with blood pressure at 150/101 and chest tightness, feeling like my heart was about to burst (this occurred while I was sitting at my computer).
On April 25, I returned for follow-up tests, including urine and blood tests, which were normal.
I had an echocardiogram (showing mitral valve prolapse and tricuspid regurgitation), a 24-hour Holter monitor (report indicated NSR, RAE, LVH), and a chest X-ray (normal heart size).
The exercise ECG was negative, but there was mild JVE.
The doctor ordered an MRA (+C) with contrast for further evaluation.
From late January to May, I have intermittently felt chest tightness and pain, particularly on the left side, with my heart rate fluctuating from fast to slow.
I would like to inquire whether my symptoms could indicate myocarditis, myocardial infarction, or if they are precursors to myocardial infarction due to inflammation, or if they could be signs of cardiomyopathy or post-viral sequelae.
On April 30, after seeing a gastroenterologist, I found that medication helped reduce my gastroesophageal reflux symptoms.
However, on the day I drove home from the appointment, I felt tightness in my shoulders and a sensation of a foreign body in my throat, accompanied by a sudden increase in heart rate and blood pressure.
I stopped and called an ambulance, but I felt better shortly afterward.
During these episodes, I always experience tightness or soreness in my shoulders that is difficult to describe.
Since I am scheduled for an MRI on May 12, I am wondering if it is necessary for me to undergo advanced cardiac CT angiography (which also requires contrast).
Could you please review my echocardiogram and exercise ECG reports? My health is very important to me, especially since I have dependents.
Thank you, Dr.
He, and I wish you peace and good health.

Chen Xiao Didi, 20~29 year old female. Ask Date: 2024/05/04

Dr. He Dongjin reply Cardiology

Hello, it seems that what you're experiencing is more related to autonomic nervous system dysfunction rather than myocarditis, myocardial infarction, or cardiomyopathy.
Please don't scare yourself; these conditions can be detected through ultrasound, and you have had several tests done with normal results.
How about your exercise electrocardiogram report? The ultrasound reports in the document show no issues, so there's no need to worry.
Changhua Hospital cares about you.

Reply Date: 2024/05/04

More Info

Understanding elevated cardiac enzymes, particularly Troponin I and CK (Creatine Kinase), is crucial in differentiating between various cardiac conditions such as myocarditis, myocardial infarction (heart attack), and cardiomyopathy. Your symptoms and the series of tests you've undergone provide valuable insights into your cardiac health.

Elevated Cardiac Enzymes: What They Indicate
1. Troponin I: This protein is released when the heart muscle is damaged. Elevated levels indicate myocardial injury, which can occur in conditions like myocardial infarction, myocarditis, or severe heart strain. Your Troponin I levels have shown significant fluctuations, peaking at 355, which indicates a period of myocardial stress or damage.

2. CK (Creatine Kinase): This enzyme is also released when there is damage to the heart muscle, but it can also be elevated due to other factors, such as muscle injury or strenuous exercise. Your CK levels have varied, with a peak of 192, which can suggest muscle involvement but is less specific than Troponin I for cardiac injury.

Differential Diagnosis
Given your symptoms and the elevated cardiac enzymes, several conditions could be considered:
- Myocarditis: This is an inflammation of the heart muscle, often caused by viral infections. Symptoms can include chest pain, fatigue, and arrhythmias. The fluctuating Troponin levels and your episodes of chest pain and palpitations could suggest myocarditis, especially if there was a preceding viral illness (like your throat infection).

- Myocardial Infarction (Heart Attack): This occurs when blood flow to a part of the heart is blocked, causing tissue damage. The significant elevation in Troponin I during your initial visits raises concern for a possible heart attack, particularly if accompanied by chest pain and other symptoms. However, the subsequent normalization of Troponin levels and the negative findings on stress tests may argue against a recent heart attack.

- Cardiomyopathy: This refers to diseases of the heart muscle that can lead to heart failure. Your echocardiogram findings of mitral valve prolapse and tricuspid regurgitation, along with symptoms of fatigue and palpitations, may suggest an underlying cardiomyopathy, particularly if there is a history of familial heart disease.

Additional Testing
Your healthcare provider's recommendation for an MRI and possibly a high-resolution CT scan is prudent. These imaging modalities can provide detailed information about the structure and function of your heart, helping to identify any areas of damage, inflammation, or structural abnormalities that may not be visible on standard echocardiograms or stress tests.

Management and Follow-Up
1. Medication: Depending on the diagnosis, medications such as beta-blockers, ACE inhibitors, or anti-inflammatory drugs may be indicated to manage symptoms and improve heart function.

2. Lifestyle Modifications: Quitting smoking, maintaining a healthy diet, and regular exercise (as tolerated) are essential for heart health.

3. Regular Monitoring: Continuous follow-up with your cardiologist is crucial, especially given your history of fluctuating symptoms and enzyme levels. Regular echocardiograms and possibly repeat cardiac enzyme tests may be necessary to monitor your condition.

4. Emergency Plan: Given your history of acute episodes, having a plan in place for when symptoms arise is vital. This may include knowing when to seek emergency care and having medications readily available.

Conclusion
Your symptoms and elevated cardiac enzyme levels warrant careful evaluation to rule out serious conditions like myocarditis or myocardial infarction. The variability in your Troponin and CK levels, along with your clinical symptoms, suggests a complex interplay of factors affecting your heart. It is essential to work closely with your healthcare provider to determine the most appropriate diagnostic and therapeutic strategies tailored to your specific situation. Regular follow-ups and adherence to treatment plans will be key in managing your heart health effectively.

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