What is the ideal modality to evaluate myocarditis?

• A. ECG
• B. CT
• C. X-ray
• D. CMR

Answer: (D)

Evaluating myocarditis relies on tissue characterization, and cardiac magnetic resonance provides the most complete noninvasive picture. CMR can identify myocardial edema (through T2 imaging or mapping), hyperemia/capillary leak (early gadolinium enhancement), and necrosis or scar (late gadolinium enhancement). The typical myocarditis pattern is subepicardial or mid-wall LGE, often in the inferolateral wall, which helps distinguish it from ischemic injury that usually involves the subendocardium in a coronary distribution. The Lake Louise Criteria use two of these tissue-based features to support a diagnosis noninvasively.

Endomyocardial biopsy can give a definitive diagnosis, but it’s invasive and not routinely required. Other modalities add context but aren’t as diagnostic for myocarditis: ECG may show nonspecific changes or arrhythmias, chest X-ray is non-specific, and CT lacks detailed tissue characterization and is better suited for ruling out coronary disease or other causes.

So, the ideal modality to evaluate suspected myocarditis is cardiac magnetic resonance.