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Background: In patients presenting with acute cardiac symptoms, abnormal ECG and raised troponin, myocarditis may be suspected after normal angiography., Aims: To analyse cardiac magnetic resonance (CMR) findings in patients with a provisional diagnosis of acute coronary syndrome (ACS) in whom acute myocarditis was subsequently considered more likely., Methods and Results: 79 patients referred for CMR following an admission with presumed ACS and raised serum troponin in whom no culprit lesion was detected were studied. 13% had unrecognised myocardial infarction and 6% takotsubo cardiomyopathy. The remainder (81%) were diagnosed with myocarditis. Mean age was 45±15 years and 70% were male. Left ventricular ejection fraction (EF) was 58±10%; myocardial oedema was detected in 58%. A myocarditic pattern of late gadolinium enhancement (LGE) was detected in 92%. Abnormalities were detected more frequently in scans performed within 2 weeks of symptom onset: oedema in 81% vs 11% (p<0.0005), and LGE in 100% vs 76% (p<0.005). In 20 patients with both an acute (<2 weeks) and convalescent scan (>3 weeks), oedema decreased from 84% to 39% (p<0.01) and LGE from 5.6 to 3.0 segments (p=0.005). Three patients presented with sustained ventricular tachycardia, another died suddenly 4 days after admission and one resuscitated 7 weeks following presentation. All 5 patients had preserved EF., Conclusions: Our study emphasises the importance of access to CMR for heart attack centres. If myocarditis is suspected, CMR scanning should be performed within 14 days. Myocarditis should not be regarded as benign, even when EF is preserved.

Cardiovascular magnetic resonance imaging (CMR) is an established clinical tool for the identification of irreversible myocardial injury. More recently, experience with stress-perfusion CMR has increased sufficiently so that this now provides an accurate and reliable aid to clinical decision-making in patients with ischaemic heart disease. T2-weighted or "black blood" imaging is a technique used less frequently to examine the myocardium but one that is growing in stature. This article explains the rationale behind the technique and reviews recent data illustrating clinical and research scenarios in which the addition of T2-weighted sequences to standard cardiac scanning protocols might be warranted.

This report illustrates a magnetic resonance image of aborted myocardial infarction after primary angioplasty. Myocardial oedema in the absence of late enhancement seems to be the magnetic resonance marker of the myocardium at risk of infarction that has been reperfused within 30 minutes and aborted in the clinic.

Objective: To demonstrate postinfarction myocardial oedema in humans with particular reference to the longitudinal course, using magnetic resonance imaging (MRI)., Design: Prospective observational study. Subjects were studied one week, one month, three months, six months, and one year after presenting with a myocardial infarct., Setting: Cardiology and magnetic resonance departments in a Danish university hospital., Patients: 10 patients (three women, seven men), mean (SEM) age 58.2 (3.20) years, with a first transmural myocardial infarct., Main Outcome Measures: Location and duration of postinfarction myocardial oedema., Results: All patients had signs of postinfarction myocardial oedema. The magnetic resonance images were evaluated by two blinded procedures, employing two MRI and two ECG observers: (1) MRI determined oedema location was compared with the ECG determined site of infarction and almost complete agreement was found; (2) the time course of postinfarction myocardial oedema was explored semiquantitatively, using an image ranking procedure. Myocardial oedema was greatest at the initial examination one week after the infarction, with a gradual decline during the following months (Spearman's rank correlation analysis: rho(observer 1) = 0.94 (p < 0.0001) and rho(observer 2) = 0.97 (p < 0.0001)). The median duration of oedema was six months., Conclusions: Postinfarction myocardial oedema seems surprisingly long lasting. This observation is of potential clinical interest because the oedema may have prognostic significance.