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CMR Diagnosis of Myocarditis — EECC MCQ

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ModerateCoronary Artery DiseaseCMR Diagnosis of MyocarditisEECC

A 48-year-old man presents with acute chest pain. Serial high-sensitivity troponin shows a rise from 5 ng/L to 45 ng/L over 3 hours (significant delta). He has no traditional cardiovascular risk factors. Angiography shows normal coronary arteries with no dissection or spasm. CMR shows subepicardial LGE in the lateral wall with corresponding oedema. What is the final diagnosis?

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Correct answer: D — Acute myocarditis — CMR showing subepicardial or mid-wall LGE in a non-coronary distribution with myocardial oedema on T2 is the hallmark pattern, distinguishing it from MI (subendocardial) and Takotsubo (oedema without significant LGE)

CMR is the gold standard non-invasive tool for diagnosing myocarditis. The updated Lake Louise Criteria (2018) require: at least one T2-based criterion (myocardial oedema on T2 mapping or T2-weighted imaging) AND at least one T1-based criterion (non-ischaemic LGE, elevated native T1, or elevated ECV). The LGE pattern in myocarditis is characteristically subepicardial or mid-wall in a non-coronary distribution (most commonly the inferolateral wall) — distinct from MI (subendocardial-to-transmural following a coronary territory). The 2025 ESC Myocarditis/Pericarditis Guidelines use the IMPS framework (Infection-Modulated Pathology Score) and recommend CMR within 2 weeks of symptom onset for optimal diagnostic sensitivity.

Reference: ESC (2025): Myocarditis/Pericarditis Guidelines; Updated Lake Louise Criteria