Manifestations of Rheumatic Carditis, Regression of Valvular Regurgitation, and Independent Predictors of Mitral Regurgitation Improvement After Rheumatic Carditis in Thai Children

Background

Acute rheumatic fever (ARF) with carditis can lead to the development of rheumatic heart disease in children and young adults.

Objective

This study aimed to investigate the manifestations of rheumatic carditis, clinically significant regression of valvular regurgitation as assessed by echocardiography, and the independent predictors of mitral regurgitation (MR) improvement after rheumatic carditis in Thai children.

Method

Children diagnosed with rheumatic carditis during 2005-2020 at Siriraj Hospital (Bangkok, Thailand) were retrospectively enrolled. Trivial, and mild regurgitation were grouped as non-clinically significant (NCS) regurgitation. Valvular regression was defined moderate-severe regurgitation improving to NCS regurgitation.

Results

Eighty-one patients (mean age: 10 years, range: 8-12 years) were included. At presentation, 59 (72.8%) patients had combined mitral regurgitation (MR) and aortic regurgitation (AR), 20 (24.6%) patients had MR alone, and 2 (2.4%) patients had AR alone. Concerning severity, 28 (34.6%) and 30 (37%) patients presented with severe and moderate MR, respectively. Severe and moderate AR was found in 9 (11.1%) and 16 (19.8%) patients, respectively. At the one-year follow-up, 43.4% of moderate-severe MR, and 41.7% of moderate-severe AR improved to NCS regurgitation. Multivariate analysis revealed high erythrocyte sedimentation rate (ESR) (p = 0.01) and severe carditis (p = 0.05) at presentation to be independent predictors of MR improvement.

Conclusion

Thai children with rheumatic carditis had a high incidence of valvular regurgitation; however, the valvular damage was improved in most patients. High ESR and severe carditis independently predict MR improvement.

Incidence rates of myocarditis and pericarditis within 30 days following homologous and heterologous BNT162b2 vaccinations in individuals 5-40 years of age

INTRODUCTION

Due to the data scarcity in low- and middle-income countries, we aimed to examine the incidence rate of myocarditis and pericarditis within 30 days after each dose of homologous (3 × BNT162b2) and heterologous prime-boost (2 × BBIBP-CorV/BNT162b2) vaccine regimen among individuals younger than 40 years.

METHODS

We conducted a historical control cohort using routinely recorded data from Thai national vaccine and insurance claims databases. Sex-specific incidence rate ratios (IRRs) for myocarditis and pericarditis were calculated for each vaccination strategy and contrasted with incidence rates among the non-immunised population in the pre-COVID-19 period. From August 2021 to September 2022, we tracked the incidence of myocarditis and pericarditis within 30 days after vaccinations using < 40-year-old national population databases. Our reference was the average monthly incidence of these conditions in the non-immunised population from August to October 2019. The exposure of interest was immunisation against the SARS-CoV-2 virus, incorporating the following vaccination strategies: three-dose 3 × BNT162b2 regimen, three-dose 2 × BBIBP-CorV/BNT162b2 regimen, and non-immunisation.

RESULTS

For myocarditis, a total of 215 cases were identified among 7,594,965 individuals in the 3 × BNT162b2 cohort, 5 cases among 2,914,643 individuals in the 2 × BBIBP-CorV/BNT162b2 cohort, and 115 cases among 32,424,780 non-immunised individuals. The sex-specific IRRs (95 % confidence intervals) of myocarditis and pericarditis after the homologous vaccination were 3.09 (1.61, 5.93) and 1.84 (0.72, 4.73) for females and 7.43 (3.11, 17.73) and 10.48 (3.90, 28.15) for males, respectively. Conversely, the IRRs of myocarditis after the heterologous vaccination were not significant (females: 2.24 (0.70, 7.17); males: 1.99 (0.48, 8.21)). IRRs could not be obtained for pericarditis after the heterologous vaccination because of the small number of observed events.

CONCLUSIONS

The study observed a significantly increased risk of myocarditis and pericarditis following homologous 3 × BNT162b2 vaccination but had insufficient power to confirm an increased risk for myocarditis following the heterologous prime-boost 2 × BBIBP-CorV/BNT162b2 vaccination. The incidence of pericarditis following the heterologous vaccination was too rare to evaluate.

Sex differences in myocarditis hospitalizations: Rates, outcomes, and hospital characteristics in the National Readmission Database

Inflammation of the myocardium, or myocarditis, presents with varied severity, from mild to life-threatening such as cardiogenic shock or ventricular tachycardia storm. Existing data on sex-related differences in its presentation and outcomes are scarce. Using the Nationwide Readmission Database (2016-2019), we identified myocarditis hospitalizations and stratified them according to sex to either males or females. Multivariable regression analyses were used to determine the association between sex and myocarditis outcomes. The primary outcome was in-hospital mortality, and the secondary outcomes included sudden cardiac death (SCD), cardiogenic shock (CS), use of mechanical circulatory support (MCS), and 90-day readmissions. We found a total of 12,997 myocarditis hospitalizations, among which 4,884 (37.6 %) were females. Compared to males, females were older (51 ± 15.6 years vs. 41.9 ± 14.8 in males) and more likely to have connective tissue disease, obesity, and a history of coronary artery disease. No differences were noted between the two groups with regards to in-hospital mortality (adjusted odds ratio [aOR] 1.20; confidence interval [CI] 0.93-1.53; P = 0.16), SCD (aOR:1.18; CI 0.84-1.64; P = 0.34), CS (aOR: 1.01; CI 0.85-1.20;P = 0.87), or use of MCS (aOR: 1.07; CI:0.86-1.34; P = 0.56). In terms of interventional procedures, females had lower rates of coronary angiography (aOR: 0.78; CI 0.70-0.88; P < 0.01), however, similar rates of right heart catheterization (aOR 0.93; CI:0.79-1.09; P = 0.36) and myocardial biopsy (aOR: 1.16; CI:0.83-1.62; P = 0.38) compared to males. Additionally, females had a higher risk of 90-day all-cause readmission (aOR: 1.25; CI: 1.16-1.56; P < 0.01) and myocarditis readmission (aOR:1.58; CI 1.02-2.44; P = 0.04). Specific predictors of readmission included essential hypertension, congestive heart failure, malignancy, and peripheral vascular disease. In conclusion, females admitted with myocarditis tend to have similar in-hospital outcomes with males; however, they are at higher risk of readmission within 90 days from hospitalization. Further studies are needed to identify those at higher risk of readmission.

Vaccine-carditis study: Spanish multicenter registry of inflammatory heart disease after COVID-19 vaccination

INTRODUCTION AND OBJECTIVES

Vaccines against SARS-CoV-2 have been a major scientific and medical achievement in the control of the COVID-19 pandemic. However, very infrequent cases of inflammatory heart disease have been described as adverse events, leading to uncertainty in the scientific community and in the general population.

METHODS

The Vaccine-Carditis Registry has included all cases of myocarditis and pericarditis diagnosed within 30 days after COVID-19 vaccination since August 1, 2021 in 29 centers throughout the Spanish territory. The definitions of myocarditis (probable or confirmed) and pericarditis followed the consensus of the Centers for Disease Control and the Clinical Practice Guidelines of the European Society of Cardiology. A comprehensive analysis of clinical characteristics and 3-month evolution is presented.

RESULTS

From August 1, 2021, to March 10, 2022, 139 cases of myocarditis or pericarditis were recorded (81.3% male, median age 28 years). Most cases were detected in the 1st week after administration of an mRNA vaccine, the majority after the second dose. The most common presentation was mixed inflammatory disease (myocarditis and pericarditis). 11% had left ventricular systolic dysfunction, 4% had right ventricular systolic dysfunction, and 21% had pericardial effusion. In cardiac magnetic resonance studies, left ventricular inferolateral involvement was the most frequent pattern (58%). More than 90% of cases had a benign clinical course. After a 3-month follow-up, the incidence of adverse events was 12.78% (1.44% mortality).

CONCLUSIONS

In our setting, inflammatory heart disease after vaccination against SARS-CoV-2 predominantly affects young men in the 1st week after the second dose of RNA-m vaccine and presents a favorable clinical course in most cases.

High rates of myocarditis with clozapine in the Hunter region of Australia

OBJECTIVE

To study the causes of clozapine treatment discontinuation and measure clozapine-induced myocarditis (CIM) rates in an Australian region, to compare the observed rates of CMI with reports from Australia and the world, and discuss factors related to CIM incidence rates in the region.

METHODS

The study is a retrospective clinical audit of 327 patients prescribed clozapine. All patients were monitored by the mandatory CIM monitoring protocol for the first six weeks of treatment. The validity of a diagnosis of CIM was assessed using six criteria. Socio-demographic and clinical factors and clozapine prescription practices were analysed for their association with CIM. The study could not examine co-existing medical illness, co-prescribed psychotropic medication, genetics, and environmental factors.

RESULTS

CIM occurred in 9.8 % of the cohort after a mean treatment duration of 19.5 days. The diagnosis of CIM was considered valid in all cases. Gender, age at the start of treatment, ethnicity, cumulative clozapine dose, dose titration, and clozapine/norclozapine ratio were unrelated to CIM.

CONCLUSION

The CIM rate in the Hunter region was higher than in the rest of Australia and the world and increased after adopting the monitoring protocol. Over-diagnosis, patient's age and gender, ethnicity, cumulative clozapine dose, dosing titration, and clozapine metabolism rate were unrelated to the high occurrence rates. The possible role of comorbid illnesses, co-prescribed psychiatric medications, genetic, and environmental factors in the etiology of CIM requires further study. The reasons underlying the high rates of CIM in the Hunter region need further exploration.

Current Clinical Profile of Acute Rheumatic Fever and Recurrent Acute Rheumatic Fever in Pakistan

Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

Long term follow up and outcomes of Covid-19 vaccine associated myocarditis in Victoria, Australia: A clinical surveillance study

BACKGROUND

Myocarditis and myopericarditis are well described adverse events of special interest (AESI) following COVID-19 vaccinations. Although reports are reassuring regarding initial clinical outcomes, information about longer term outcomes remains limited. We aimed to further this knowledge and report outcomes to 6 months post diagnosis from a single population cohort.

METHODS

Reports of myocarditis following COVID-19 vaccination were followed up by SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), the state-wide vaccine safety service for Victoria, Australia. Confirmed myocarditis cases (Brighton Collaboration Criteria levels 1-3) were followed up via surveys at 1, 3 and 6 months post symptom onset. Responses received between 22 February 2021 and 30 September 2022 were analysed.

RESULTS

87.5 % (N = 182) of eligible participants completed at least 1 survey report. 377 reports were analysed. 76.9 % of completed reports were from male patients. The median age of patients was 21 years [IQR: 16 to 32]. 54.8 % (n = 74) of survey reports at 6 months, reported ongoing symptoms. At all follow-up time points, females were significantly more likely to have ongoing symptoms. At 6 months, 51.9 % of male respondents reported symptom resolution compared to 22.6 % of female patients (p = 0.002). Females were also more likely to continue medication and have ongoing exercise restrictions. However, males were significantly more likely to have higher initial peak troponin results and abnormal initial cardiac imaging investigations.

CONCLUSIONS

There appears to be a significant proportion of patients who experience ongoing symptoms to 6 months post onset amongst patients that experience these AESI. Male patients were more likely to report earlier and more complete symptom recovery, despite significantly higher average initial peak troponin. This difference in phenotypic presentation in females compared to males warrants further investigation and there is a need for longer term follow up data.

Overview of SARS-CoV-2 infection and vaccine associated myocarditis compared to non-COVID-19-associated myocarditis: A systematic review and meta-analysis

BACKGROUND

Previous literature suggests that both SARS-CoV-2 infection and COVID-19 mRNA vaccine are associated with myocarditis, in which the incidence is higher in the infection group. COVID-19 mRNA vaccine-related myocarditis is noted to have a more benign course. Despite these findings, there is a need for a larger population systematic review that compares the outcomes to pre-pandemic acute myocarditis to better understand the extent of the current post-COVID state.

METHODS

We performed a literature search with PubMed and EMBASE and identified studies investigating COVID-19 and its vaccinated population, and the population prior to the pandemic (control group) who had myocarditis. We performed a one-group meta-analysis of the incidence, baseline demographics, and outcomes of myocarditis for each group.

RESULTS

The incidence in the SARS-CoV-2 infection group was 2.76 per thousand (95% CI, 0.85-8.92), 19.7 per million (95% CI, 12.3-31.6) in the vaccine group, and 0.861 per million (95% CI, 0.04-16.7) in the control group. The majority of patients were male, with the highest proportion in the vaccine group. The mean age was the youngest in the vaccine group (24.8, 95% CI, 19.1-30.6). The vaccine group had the lowest mortality (2.0%, 95% CI, 1.3-2.7) followed by the control and the SARS-CoV-2 infection group. The vaccine group had the lowest proportion of immunoglobulin and glucocorticoid use, mechanical circulatory support, and cardiogenic shock.

CONCLUSION

Our study showed favorable outcomes of myocarditis in patients with COVID-19 mRNA vaccination, despite a higher incidence than pre-COVID controls. Further studies with standardized myocarditis diagnostic criteria assessing long-term outcomes are necessary.

Global, Regional, and National Burden of Myocarditis in 204 Countries and Territories From 1990 to 2019: Updated Systematic Analysis

BACKGROUND

Myocarditis is characterized by high disability and mortality, and imposes a severe burden on population health globally. However, the latest global magnitude and secular trend of myocarditis burden have not been reported.

OBJECTIVE

This study aimed to delineate the epidemiological characteristics of myocarditis burden globally for optimizing targeted prevention and research.

METHODS

Based on the Global Burden of Disease Study 2019, the myocarditis burden from 1990 to 2019 was modeled using the Cause of Death Ensemble tool, DisMod-MR, and spatiotemporal Gaussian regression. We depicted the epidemiology and trends of myocarditis by sex, age, year, region, and sociodemographic index (SDI). R program version 4.2.1 (R Project for Statistical Computing) was applied for all statistical analyses, and a 2-sided P-value of <.05 was considered statistically significant.

RESULTS

The number of incident cases (1,268,000) and deaths (32,450) associated with myocarditis in 2019 increased by over 1.6 times compared with the values in 1990 globally. On the other hand, the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) decreased slightly from 1990 to 2019. The disability-adjusted life years (DALYs) decreased slightly in the past 3 decades, while the age-standardized DALY rate (ASDR) decreased greatly from 18.29 per 100,000 person-years in 1990 to 12.81 per 100,000 person-years in 2019. High SDI regions always showed a more significant ASIR. The ASIR slightly decreased in all SDI regions between 1990 and 2019. Middle SDI regions had the highest ASMR and ASDR in 2019. Low SDI regions had the lowest ASMR and ASDR in 2019. The age-standardized rates (ASRs) of myocarditis were higher among males than among females from 1990 to 2019 globally. All ASRs among both sexes had a downward trend, except for the ASMR among males, which showed a stable trend, and females had a more significant decrease in the ASDR than males. Senior citizens had high incident cases and deaths among both sexes in 2019. The peak numbers of DALYs for both sexes were noted in the under 1 age group in 2019. At the national level, the estimated annual percentage changes in the ASRs had significant negative correlations with the baseline ASRs in 1990.

CONCLUSIONS

Globally, the number of incident cases and deaths associated with myocarditis have increased significantly. On the other hand, the ASRs of myocarditis showed decreasing trends from 1990 to 2019. Males consistently showed higher ASRs of myocarditis than females from 1990 to 2019 globally. Senior citizens gradually predominated in terms of myocarditis burden. Policymakers should establish targeted control strategies based on gender, region, age, and SDI; strengthen aging-related health research; and take notice of the changes in the epidemic characteristics of myocarditis.

Contemporary National Trends of Mechanical Circulatory Support Among Myocarditis Hospitalizations Before the Pandemic: A National In-patient Database (2005-2019) Study

According to the Global Burden of Disease Project, the morbidity and mortality of myocarditis continue to be a significant worldwide burden. On October 1, 2015, hospital administrative data started using the International Classification of Diseases (ICD)-10 codes instead of the ICD-9. To our knowledge, nationwide trends of myocarditis have not been studied after this update. The NIS database from 2005-2019 was analyzed using ICD-9 and 10 codes. Our search yielded 141,369 hospitalizations due to myocarditis, with 40.9% females. There were 6627 (4.68%) patients who required mechanical circulatory support (MCS) using left ventricular assisted devices (LVAD), intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO). The use of LVAD and ECMO increased significantly during the study period (p-trend 0.003 and <0.001, respectively), whereas the use of IABP decreased during the same period (p-trend 0.025). Our study demonstrated an overall increase in the use of MCS overall in myocarditis, with increasing utilization of more advanced MCS in the forms of LVAD and ECMO.

Unveiling the Dual Threat: Myocarditis in the Spectrum of Dengue Fever

This meta-analysis aims to systematically review and analyze available studies on the association between myocarditis and dengue viral fever. A comprehensive literature search was carried out using several databases. Mantel-Haenszel odds ratios and associated 95% confidence intervals were produced to report the overall effect size using random effect models. Besides, random effects models were used to calculate the overall pooled prevalence. Data from 26 articles (6622 dengue patients) showed that pooled estimate of myocarditis in dengue fever was 12.4% (95% CI, 8.41-17.08). Higher prevalence was seen in reports from Asia (15.2%) compared to that from Latin America (3.6%). Besides, the pooled prevalence of severity and mortality was 34% (95% CI, 20.49-49.04) and 26.44% (95% CI, 18.07-35.78) respectively. Significantly higher prevalence rates of severe disease in the pediatric population (52.4%) and studies with a higher percentage of females (52.1%) were also observed. However, higher mortality rates were seen in the adult population (34.8%) compared with the pediatric age group. Further, myocarditis in dengue patients was associated with increased risk of severity (RR = 2.44, 95% CI 1.007-5.93, P = 0.048) and mortality (RR = 19.41, 95% CI 7.19-52.38, P < 0.001) compared with dengue patients without myocarditis. No significant publication bias was evident in the meta-analysis. The findings highlight the clinical significance of early identification and management of myocarditis in patients with dengue fever.

Myocarditis Screening Methods in Athletes After SARS-CoV-2 Infection - a Systematic Review

This review aims to elucidate the myocarditis incidence in SARS-CoV-2-positive athletes and to evaluate different screening approaches to derive sports cardiological recommendations after SARS-CoV-2 infection. The overall incidence of athletes (age span 17-35 years, 70% male) with myocarditis after SARS-CoV-2 infection was 1.2%, with a high variation between studies (which contrasts an incidence of 4.2% in 40 studies within the general population). Studies that used conventional screening based on symptoms, electrocardiogram, echocardiography, and cardiac troponin - only followed by cardiac magnetic resonance imaging in case of abnormal findings - reported lower myocarditis incidences (0.5%, 20/3978). On the other hand, advanced screening that included cardiac magnetic resonance imaging within the primary screening reported higher incidences (2.4%, 52/2160). The sensitivity of advanced screening seems to be 4.8 times higher in comparison to conventional screening. However, we recommend prioritization of conventional screening, as the economical load of advanced screening for all athletes is high and the incidence of myocarditis in SARS-CoV-2-positive athletes and the risk of adverse outcomes seems low. Future research will be important to analyze the long-term effects of myocarditis after infection with SARS-CoV-2 in athletes for risk stratification to optimally guide a safe return to sport.

Comment on: Acute Myocarditis and Pericarditis After mRNA COVID-19 Vaccinations: A Single-Centre Retrospective Analysis

We have thoroughly reviewed the research conducted by Marina et al., titled "Acute Myocarditis and Pericarditis After mRNA COVID-19 Vaccinations—A Single-Centre Retrospective Analysis" [1]. We commend the authors for their diligent work in presenting a concise and informative report. While we agree with the overall findings of the study, which indicate a moderate risk of myopericarditis following mRNA COVID-19 vaccinations, particularly among young males, we would like to draw attention to several areas where the conclusion could have been strengthened. Firstly, it is crucial to acknowledge that retrospective studies possess inherent limitations such as recollection bias and potential inaccuracies in patient documentation. These issues could have been mitigated by including actual cases from the relevant period. Additionally, conducting the study across multiple hospitals or utilizing national databases would have helped address any bias arising from distinct socioeconomic, health, and environmental factors [2].

BNT162b2 immunization-related myocarditis in adolescents and consequent hospitalization: Report from a medical center

BACKGROUND

To investigate Pfizer-BioNTech 162b2 mRNA COVID-19 vaccine (BNT162b2) immunization-related myocarditis and describe the risk factors for consequent hospitalization in the pediatric intensive care unit (PICU) in children between 12 and 18 years.

METHODS

Children and adolescents 12 years of age and older who presented with discomfort after BNT162b2 immunization (BNTI) and visited pediatric emergency room (PER) at Chang Gung Memorial Hospital from September 22, 2021 to March 21, 2022, were included for analysis.

RESULTS

681 children presented with discomfort after BNTI and visited our PER. The mean age was 15.1 ± 1.7 years. Three hundred and ninety-four (57.9%) and 287 (42.1%) events were after 1st and 2nd dose, respectively. 58.4% (n = 398) were male. The most common complaints were chest pain (46.7%) and chest tightness (27.0%). The median (interquartile range [IQR]) interval of discomfort after BNTI was 3.0 (1.0-12.0) days. BNTI-related pericarditis, myocarditis and myopericarditis were diagnosed in 15 (2.2%), 12 (1.8%) and 2 (0.3%) patients, respectively. Eleven (1.6%) needed hospitalization in PICU. The median (IQR) hospital stay was 4.0 (3.0-6.0) days. There was no mortality. More patients were diagnosed myocarditis (p = 0.004) after 2nd dose BNTI. PICU admission occurred more commonly after 2nd dose BNTI (p = 0.007). Risk factors associated with hospitalization in PICU were abnormal EKG findings (p = 0.047) and abnormal serum troponin levels (p = 0.003) at PER.

CONCLUSION

Myocarditis in children aged 12-18 years occurred more commonly following 2nd dose BNTI. Most cases were of mild or intermediate severity without death. Factors predicting BNTI-related myocarditis and consequent hospitalization in PICU were abnormal EKG findings and abnormal serum troponin levels at PER in this study.

Cardiac manifestations of multisystem inflammatory syndrome of children after SARS-CoV-2 infection: a systematic review and meta-analysis

This systematic review and meta-analysis were conducted to evaluate the prevalence of cardiac manifestations associated with multisystem inflammatory syndrome in children worldwide. We conducted electronic searches in Ovid MEDLINE, Ovid EMBASE, and the World Health Organization COVID-19 Literature Database from the inception of the SARS-CoV-2 pandemic to 1 January, 2022. Three authors independently screened the abstracts to determine eligibility, assessed methodology in the full texts, and extracted the data.We identified 2848 citations; 94 studies (14,932 patients) were included. The prevalence of vasopressors was 48.2% (95% CI 45.1%, 51.3%), left ventricular systolic dysfunction occurred in 37.2% (95% CI 34.1%, 40.3%), myocarditis in 34.1% (95% CI 30.5%, 37.8%), electrocardiographic dysrhythmias and abnormalities detected in 23.1% (95% CI 18.8%, 27.6%), coronary abnormalities identified in 18% (95% CI 16%, 20%), extracorporeal membrane oxygenation deployed in 2.2% (95% CI 1.7%, 2.8%), and mortality rate of 2.2% (95% CI 1.7%, 2.7%). A sensitivity analysis was performed after removing eleven studies with high bias, and the adjusted prevalence was not different than the original evaluation.In this meta-analysis of the largest cohort of multisystem inflammatory syndrome in children patients to date, we established the most accurate prevalence of the most common cardiac manifestations. Providers will subsequently have more precise data to anticipate patient outcomes and approach discussions concerning the frequency of monitoring outside the acute hospital period.

Trends in the Incidence of Cardiogenic Shock, and Utilization of Mechanical Circulatory Support in Myocarditis: Insights from the National Inpatient Sample 2016 to 2019

A subset of patients with myocarditis present with cardiogenic shock. There is a lack of contemporary data assessing the use of mechanical circulatory support (MCS) in these patients. Myocarditis hospitalizations were analyzed using the National Inpatient Sample between 2016 and 2019. Characteristics of patients with and without cardiogenic shock were assessed. Trends in mortality, MCS, right-sided cardiac catheterization (RHC) and endomyocardial biopsy were evaluated. The impact of RHC on consequent MCS and mortality was studied. A total of 38,300 hospitalizations for myocarditis were included in the study, of which 3,490 hospitalizations (9.1%) had cardiogenic shock. Patients with cardiogenic shock were older (p <0.001) and had more chronic kidney disease and atrial fibrillation. Between 2016 and 2019, there was an increase in myocarditis admissions but no difference in rates of cardiogenic shock and mortality and the use of extracorporeal membrane oxygenation, percutaneous ventricular assist devices, intra-aortic balloon pumps, left ventricular assist devices, and cardiac transplant. The most common form of MCS used in myocarditis was extracorporeal membrane oxygenation. The rates of RHC (p = 0.02) and endomyocardial biopsy (p = 0.03) increased over time. Patients who underwent RHC were more likely to receive mechanical support, and in patients with shock, RHC was associated with lower mortality (adjusted odds ratio 0.34, p <0.01). Myocarditis admissions increased over time but with no increase in the rates of cardiogenic shock and MCS. In patients with cardiogenic shock, RHC resulted in lower mortality.

[Safety aspects during treatment with clozapine. : Monitoring and rechallenge - a narrative review]

BACKGROUND

Due to its unique efficacy in treatment-resistant schizophrenia, discontinuation of treatment with clozapine is frequently associated with a significant worsening of symptoms, but also with an increased risk of suicide. Based on the literature, this review aims at summarizing different monitoring recommendations in order to be able to continue this therapy despite the occurrence of side effects. In addition, we provide recommendations when rechallenge of a previously stopped treatment with clozapine can be considered and when a definite discontinuation must take place.

MATERIAL AND METHODS

Medline, the Guideline for the use of clozapine 2013 of the Netherlands Clozapine Collaboration Group, and the S3 Guideline for Schizophrenia of the German Association of Psychiatry, Psychotherapy and Psychosomatics were searched for relevant literature, the last query dating from April 28th, 2023.

RESULTS

If agranulocytosis or cardiomyopathy develops, treatment with clozapine must be discontinued and should not be resumed thereafter. In contrast, treatment with clozapine which had to be discontinued due to myocarditis or prolongation of the QTc interval may be continued if left ventricular function is normal or after normalization of the QTc interval. Other side effects are usually not absolute contraindications for rechallenge but often require the adjunctive use of additional pharmacologic and non-pharmacologic measures.

CONCLUSION

Taking into consideration various monitoring recommendations, cessation of treatment with clozapine can often be prevented or treatment with clozapine that has been discontinued due to side effects can be resumed.

Do COVID-19 viral infection and its mRNA vaccine carry an equivalent risk of myocarditis? Review of the current evidence, insights, and future directions

According to recent epidemiological analysis, the percentage of world population infected with COVID-19 by end of December 2020 is approximately 12.56%1. COVID induced acute care and ICU hospitalization rates are around 9.22 (95% CI: 18.73-19.51), and 4.14 (95% CI: 4.10-4.18) per 1000 population1. Although therapeutic strategies such as antivirals, intravenous immunoglobulins and corticosteroids have shown modest efficacy in reducing the disease progression, they are not disease specific and only temper the immune mediated attack on the systemic tissues. Therefore, clinicians started to rely on mRNA COVID-19 vaccines, which are clinically efficacious in reducing the incidence, disease severity and systemic complications of COVID-19 infections. Nevertheless, usage of COVID-19 mRNA vaccines is also associated with cardiovascular complications such as myocarditis and pericarditis. On the other hand, COVID-19 infections itself are associated with cardiovascular complications such as myocarditis. The underlying signaling pathways for occurrence of COVID-19 and mRNA COVID-19 vaccine induced myocarditis are quite different although there is some overlap in autoimmunity and cross reactivity mechanisms. With media reports highlighting the cardiovascular complications of COVID-19 vaccines such as myocarditis, general population have become more hesitant and uncertain regarding the safety and efficacy of these mRNA vaccines. We plan to review the current literature and provide insights into their pathophysiological mechanisms for myocarditis and offer recommendations for further research studies in this regard. This will hopefully dispel some doubts and encourage more people to be vaccinated for preventing the risk of COVID-19 induced myocarditis and other associated cardiovascular complications.

One-Year Risk of Myocarditis After COVID-19 Infection: A Systematic Review and Meta-analysis

BACKGROUND

Acute myocarditis has been described as a relatively rare cardiovascular complication of COVID-19 infection. However, data regarding the risk of myocarditis during the post-acute phase of COVID-19 are scant. We assess the risk of incident myocarditis in COVID-19 survivors within 1 year from the index infection by a systematic review and meta-analysis of the available data.

METHODS

Data were obtained by searching Medline and Scopus for all studies published at any time up to September 1, 2022, and reporting the long-term risk of incident myocarditis in COVID-19 survivors. Myocarditis risk data were pooled using the Mantel-Haenszel random-effects models with hazard ratio (HR) as the effect measure with 95% confidence interval (CI). Heterogeneity among studies was assessed using the Higgins-Thompson I2 statistic.

RESULTS

Overall, 20,875,843 patients (mean age 56.1 years, 59.1% male) were included in this analysis. Of them, 1,245,167 experienced (and survived) COVID-19 infection. Over a mean follow-up of 9.5 months, myocarditis occurred to 0.21 (95% CI 0.13-0.42) out of 1000 patients survived to COVID-19 infection compared with 0.09 [95% CI 0.07-0.12) out of 1000 control subjects. Pooled analysis revealed that recovered COVID-19 patients presented an increased risk of incident myocarditis (HR 5.16, 95% CI 3.87-6.89; P < 0.0001; I2 = 7.9%) within 1 year from the index infection. The sensitivity analysis confirmed yielded results.

CONCLUSIONS

Our findings suggest that myocarditis represents a relatively rare but important post-acute COVID-19 sequelae.

Vaccination-Associated Myocarditis and Myocardial Injury

SARS-CoV-2 vaccine-associated myocarditis/myocardial injury should be evaluated in the contexts of COVID-19 infection, other types of viral myocarditis, and other vaccine-associated cardiac disorders. COVID-19 vaccine-associated myocardial injury can be caused by an inflammatory immune cell infiltrate, but other etiologies such as microvascular thrombosis are also possible. The clinical diagnosis is typically based on symptoms and cardiac magnetic resonance imaging. Endomyocardial biopsy is confirmatory for myocarditis, but may not show an inflammatory infiltrate because of rapid resolution or a non-inflammatory etiology. Myocarditis associated with SARS-COVID-19 vaccines occurs primarily with mRNA platform vaccines, which are also the most effective. In persons aged >16 or >12 years the myocarditis estimated crude incidences after the first 2 doses of BNT162b2 and mRNA-1273 are approximately 1.9 and 3.5 per 100 000 individuals, respectively. These rates equate to excess incidences above control populations of approximately 1.2 (BNT162b2) and 1.9 (mRNA-1273) per 100 000 persons, which are lower than the myocarditis rate for smallpox but higher than that for influenza vaccines. In the studies that have included mRNA vaccine and SARS-COVID-19 myocarditis measured by the same methodology, the incidence rate was increased by 3.5-fold over control in COVID-19 compared with 1.5-fold for BNT162b2 and 6.2-fold for mRNA-1273. However, mortality and major morbidity are less and recovery is faster with mRNA vaccine-associated myocarditis compared to COVID-19 infection. The reasons for this include vaccine-associated myocarditis having a higher incidence in young adults and adolescents, typically no involvement of other organs in vaccine-associated myocarditis, and based on comparisons to non-COVID viral myocarditis an inherently more benign clinical course.

COVID-19, Myocarditis and Pericarditis

Viral infections are a leading cause of myocarditis and pericarditis worldwide, conditions that frequently coexist. Myocarditis and pericarditis were some of the early comorbidities associated with SARS-CoV-2 infection and COVID-19. Many epidemiologic studies have been conducted since that time concluding that SARS-CoV-2 increased the incidence of myocarditis/pericarditis at least 15× over pre-COVID levels although the condition remains rare. The incidence of myocarditis pre-COVID was reported at 1 to 10 cases/100 000 individuals and with COVID ranging from 150 to 4000 cases/100 000 individuals. Before COVID-19, some vaccines were reported to cause myocarditis and pericarditis in rare cases, but the use of novel mRNA platforms led to a higher number of reported cases than with previous platforms providing new insight into potential pathogenic mechanisms. The incidence of COVID-19 vaccine-associated myocarditis/pericarditis covers a large range depending on the vaccine platform, age, and sex examined. Importantly, the findings highlight that myocarditis occurs predominantly in male patients aged 12 to 40 years regardless of whether the cause was due to a virus-like SARS-CoV-2 or associated with a vaccine-a demographic that has been reported before COVID-19. This review discusses findings from COVID-19 and COVID-19 vaccine-associated myocarditis and pericarditis considering the known symptoms, diagnosis, management, treatment, and pathogenesis of disease that has been gleaned from clinical research and animal models. Sex differences in the immune response to COVID-19 are discussed, and theories for how mRNA vaccines could lead to myocarditis/pericarditis are proposed. Additionally, gaps in our understanding that need further research are raised.

Mild-to-Moderate COVID-19 Infection and Myocarditis: A Review

The coronavirus disease 2019 (COVID-19) pandemic has taken a massive toll on healthcare systems internationally. Severe illness has been seen in a range of patient populations, but those living with cardiovascular disease have suffered to a greater extent, likely because of their comorbidities. In patients with diabetes, hypertension, heart failure, and other chronic illnesses, COVID-19 has manifested severe illnesses such as coagulopathies, myocarditis, and arrhythmias, complicating the disease course for those already suffering from underlying illness. There have been numerous studies done exploring the cardiovascular complications of COVID-19. Some of the more concerning findings have revealed a correlation between severe illness and the increasing likelihood for developing cardiovascular manifestations. However, what is more concerning were the studies revealing the presence of myocarditis and other cardiac sequelae in previously healthy patients with mild or asymptomatic COVID-19. The goal of this article is to review the literature to compile information available about whether there is a significant risk of myocarditis in those patients who do not develop severe initial COVID-19 disease.