Prevalence and clinical outcomes of myocarditis and pericarditis in 718,365 COVID-19 patients

Effect of rifampicin administration on CYP induction in a dermatomyositis patient with vasospastic angina attributable to nilmatrelvir/ritonavir-induced blood tacrolimus elevation: A case report

Ritonavir (RTV), which is used in combination with nilmatrelvir (NMV) to treat coronavirus disease 2019 (COVID-19), inhibits cytochrome P450 (CYP) 3A, thereby increasing blood tacrolimus (TAC) levels through a drug-drug interaction (DDI). We experienced a case in which a DDI between the two drugs led to markedly increased blood TAC levels, resulting in vasospastic angina (VSA) and acute kidney injury (AKI). Rifampicin (RFP) was administered to induce CYP3A and promote TAC metabolism. A 60-year-old man with dermatomyositis who was taking 3 mg/day TAC contracted COVID-19. The patient started oral NMV/RTV therapy, and he was admitted to the hospital after 4 days because of chest pain and AKI. On day 5, his blood TAC level increased markedly to 119.8 ng/mL. RFP 600 mg was administered once daily for 3 days, and his blood TAC level decreased to the therapeutic range of 9.6 ng/mL on day 9, leading to AKI improvement. Transient complete atrioventricular block and nonsustained ventricular tachycardia were present during chest pain. In the coronary spasm provocation test, complete occlusion was observed in the right coronary artery, leading to a diagnosis of VSA. VSA and AKI are possible side effects of high blood TAC levels caused by DDI, and attention should be paid to cardiovascular side effects such as VSA and AKI associated with increased blood levels of TAC when it is used together with NMV/RTV. When blood levels of TAC increase, oral RFP can rapidly decrease TAC blood levels and potentially reduce its toxicity.

COVID-19 in the Initiation and Progression of Atherosclerosis: Pathophysiology During and Beyond the Acute Phase

The incidence of atherosclerotic cardiovascular disease is increasing globally, especially in low- and middle-income countries, despite significant efforts to reduce traditional risk factors. Premature subclinical atherosclerosis has been documented in association with several viral infections. The magnitude of the recent COVID-19 pandemic has highlighted the need to understand the association between SARS-CoV-2 and atherosclerosis. This review examines various pathophysiological mechanisms, including endothelial dysfunction, platelet activation, and inflammatory and immune hyperactivation triggered by SARS-CoV-2 infection, with specific attention on their roles in initiating and promoting the progression of atherosclerotic lesions. Additionally, it addresses the various pathogenic mechanisms by which COVID-19 in the post-acute phase may contribute to the development of vascular disease. Understanding the overlap of these syndromes may enable novel therapeutic strategies. We further explore the need for guidelines for closer follow-up for the often-overlooked evidence of atherosclerotic cardiovascular disease among patients with recent COVID-19, particularly those with cardiometabolic risk factors.

Results From the Big Ten COVID-19 Cardiac Registry: Impact of SARS-COV-2 on Myocardial Involvement

OBJECTIVE

COVID-19 has been associated with myocardial involvement in collegiate athletes. The first report from the Big Ten COVID-19 Cardiac Registry (Registry) was an ecological study that reported myocarditis in 37 of 1597 athletes (2.3%) based on local clinical diagnosis. Our objective was to assess the relationship between athlete and clinical characteristics and myocardial involvement.

DESIGN

Cross-sectional study.

SETTING

We analyzed data from 1218 COVID-19 positive Big Ten collegiate athletes who provided informed consent to participate in the Registry.

PARTICIPANTS

1218 athletes with a COVID-19-positive PCR test before June 1, 2021.

ASSESSMENT OF INDEPENDENT VARIABLES

Demographic and clinical characteristics of athletes were obtained from the medical record.

MAIN OUTCOME MEASURES

Myocardial involvement was diagnosed based on local clinical, cardiac magnetic resonance (CMR), electrocardiography, troponin assay, and echocardiography. We assessed the association of clinical factors with myocardial involvement using logistic regression and estimated the area under the receiver operating characteristic (ROC) curve.

RESULTS

25 of 1218 (2.0%) athletes met criteria for myocardial involvement. The logistic regression model used to predict myocardial involvement contained indicator variables for chest pain, new exercise intolerance, abnormal echocardiogram (echo), and abnormal troponin. The area under the ROC curve for these indicators was 0.714. The presence of any of these 4 factors in a collegiate athlete who tested positive for COVID-19 would capture 55.6% of cases. Among noncases without missing data, 86.9% would not be flagged for possible myocardial involvement.

CONCLUSION

Myocardial involvement was infrequent. We predicted case status with good specificity but deficient sensitivity. A diagnostic approach for myocardial involvement based exclusively on symptoms would be less sensitive than one based on symptoms, echo, and troponin level evaluations. Abnormality of any of these evaluations would be an indication for CMR.

Identification of the needs of individuals affected by COVID-19

BACKGROUND

The optimal management of COVID-19 symptoms and their sequelae remains an important area of clinical research. Policy makers have little scientific data regarding the effects on the daily life of affected individuals and the identification of their needs. Such data are needed to inform effective care policy.

METHODS

We studied 639 people with COVID-19 resident in France via an online questionnaire. They reported their symptoms, effects on daily life, and resulting needs, with particular focus on olfaction.

RESULTS

The results indicate that a majority of participants viewed their symptoms as disabling, with symptoms affecting their physical and mental health, social and professional lives. 60% of the individuals reported having unmet medical, psychological and socio-professional support needs. Finally, affected individuals were concerned about the risk and invasiveness of possible treatments as shown by a preference for non-invasive intervention over surgery to cure anosmia.

CONCLUSIONS

It is important that policy makers take these needs into consideration in order to assist affected individuals to regain a normal quality of life.

Sacubitril-valsartan vs ACE/ARB in pediatric heart failure: A retrospective cohort study

BACKGROUND

The first angiotensin receptor/neprilysin inhibitor on the market, sacubitril-valsartan, has shown marked improvements in death and hospitalization for heart failure among adults, and is now approved for use in pediatric heart failure. While the ongoing PANORAMA-HF trial is evaluating the effectiveness of sacubitril-valsartan for pediatric patients with a failing systemic left ventricle, the enrollment criteria do not include the majority of pediatric heart failure patients. Additional studies are needed.

METHODS

Using the TriNetX database, we performed a propensity score matched, retrospective cohort study to assess the incidence of a composite of all-cause mortality or heart transplant within 1 year. The 519 patients who received sacubitril-valsartan were compared to 519 matched controls who received an angiotensin converting enzyme inhibitor (ACE) or angiotensin II receptor blocker (ARB).

RESULTS

There was no significant difference in the incidence of the composite outcome with sacubitril-valsartan over an ACE/ARB (13.3% vs 13.2%, p = 0.95), or among the components of mortality (5.0% vs 5.8%, p = 0.58) or heart transplantation (8.7% vs 7.5%, p = 0.50). Patients who were receiving full goal-directed medical therapy (14.4% vs 16.0%, p = 0.55) also showed no difference in the composite outcome. We observed a significantly increased incidence of hypotension (10% vs 5.2%, p = 0.006) and a trend toward reduced number of hospitalizations per year (mean (SD) 1.3 (4.4) vs 2.0 (9.1), p = 0.09).

CONCLUSIONS

Sacubitril-valsartan is not associated with a decrease in the composite of all-cause mortality or heart transplantation within 1 year. Future studies should evaluate the possible reduction in hospitalizations and optimal dosing to minimize hypotension.

Myocardial Strain for the Differentiation of Myocardial Involvement in the Post-Acute Sequelae of COVID-19-A Multiparametric Cardiac MRI Study

Myocardial involvement was shown to be associated with an unfavorable prognosis in patients with COVID-19, which could lead to fatal outcomes as in myocardial injury-induced arrhythmias and sudden cardiac death. We hypothesized that magnetic resonance imaging (MRI) myocardial strain parameters are sensitive markers for identifying subclinical cardiac dysfunction associated with myocardial involvement in the post-acute sequelae of COVID-19 (PASC). This study evaluated 115 subjects, including 65 consecutive COVID-19 patients, using MRI for the assessment of either post-COVID-19 myocarditis or other cardiomyopathies. Subjects were categorized, based on the results of the MRI exams, as having either 'suspected' or 'excluded' myocarditis. A control group of 50 matched individuals was studied. Along with parameters of global cardiac function, the MRI images were analyzed for measurements of the myocardial T1, T2, extracellular volume (ECV), strain, and strain rate. Based on the MRI late gadolinium enhancement and T1/T2/ECV mappings, myocarditis was suspected in 7 out of 22 patients referred due to concern of myocarditis and in 9 out of 43 patients referred due to concern of cardiomyopathies. The myocardial global longitudinal, circumferential, and radial strains and strain rates in the suspected myocarditis group were significantly smaller than those in the excluded myocarditis group, which in turn were significantly smaller than those in the control group. The results showed significant correlations between the strain, strain rate, and global cardiac function parameters. In conclusion, this study emphasizes the value of multiparametric MRI for differentiating patients with myocardial involvement in the PASC based on changes in the myocardial contractility pattern and tissue structure.

Pathogenic pathways and therapeutic targets of inflammation in heart diseases: A focus on Interleukin-1

BACKGROUND

An exuberant and dysregulated inflammatory response contributes to the development and progression of cardiovascular diseases (CVDs).

METHODS

This narrative review includes original articles and reviews published over the past 20 years and found through PubMed. The following search terms (or combination of terms) were considered: "acute pericarditis," "recurrent pericarditis," "myocarditis," "cardiac sarcoidosis," "atherosclerosis," "acute myocardial infarction," "inflammation," "NLRP3 inflammasome," "Interleukin-1" and "treatment."

RESULTS

Recent evidence supports the role of inflammation across a wide spectrum of CVDs including myocarditis, pericarditis, inflammatory cardiomyopathies (i.e. cardiac sarcoidosis) as well as atherosclerotic CVD and heart failure. Interleukins (ILs) are the signalling mediators of the inflammatory response. The NACHT, leucine-rich repeat and pyrin-domain containing protein 3 (NLRP3) inflammasome play a key role in producing IL-1β, the prototypical pro-inflammatory cytokine involved in CVDs. Other pro-inflammatory cytokines (e.g. tumour necrosis factor) have been implicated in cardiac sarcoidosis. As a proof of this, IL-1 blockade has been proven efficacious in pericarditis and chronic coronary syndrome.

CONCLUSION

Tailored strategies aiming at quenching the inflammatory response have emerged as promising to treat CVDs. In this review article, we summarize recent evidence regarding the role of inflammation across a broad spectrum of CVDs. We also review novel evidence regarding targeted therapeutic strategies.

Myocarditis mortality with and without COVID-19: insights from a national registry

BACKGROUND

Myocarditis in context of a SARS-CoV-2 infection is vividly discussed in the literature. Real-world data however are sparse, and relevance of the myocarditis diagnosis to outcome in coronavirus disease (COVID-19) is unclear.

PATIENTS AND METHODS

Retrospective analysis of 75,304 patients hospitalized in Germany with myocarditis between 2007 and 2020 is reported by DESTATIS. Patients hospitalized between 01/2016 and 12/2019 served as reference cohort for the COVID-19 patients hospitalized in 2020.

RESULTS

A total of 75,304 patients were hospitalized between 2007 and 2020 (age 42.5 years, 30.1% female, hospital mortality 2.4%). In the reference cohort, 24,474 patients (age 42.8 years, 29.5% female, hospital mortality 2.2%) were registered. In 2020, annual myocarditis hospitalizations dropped by 19.6% compared to reference (4921 vs. 6119 annual hospitalization), of which 443/4921 (9.0%) were connected to COVID-19. In 2020, hospital mortality of myocarditis in non-COVID-19 patients increased significantly compared to reference (2.9% vs. 2.2%, p = 0.008, OR 1.31, 95% CI 1.08-1.60). In COVID-19 myocarditis, hospital mortality was even higher compared to reference (13.5% vs. 2.2%, p < 0.001, OR 6.93, 95% CI 5.18-9.18).

CONCLUSION

The burden of patients with myocarditis and COVID-19 in 2020 was low. Hospital mortality was more than sixfold higher in patients with myocarditis and COVID-19 compared to those with myocarditis but without COVID-19.

Improvement of Symptoms and Cardiac Magnetic Resonance Abnormalities in Patients with Post-Acute Sequelae of SARS-CoV-2 Cardiovascular Syndrome (PASC-CVS) after Guideline-Oriented Therapy

Cardiac magnetic resonance (CMR) studies reported CMR abnormalities in patients with mild-moderate SARS-CoV-2 infection, suggesting ongoing myocardial inflammation. Patients (n = 278, 43 ± 13 years, 70.5% female) with post-acute sequelae of SARS-CoV-2 cardiovascular syndrome (PASC-CVS) were included prospectively into the Vienna POSTCOV Registry between March 2021 and March 2023 (clinicaltrials.gov NCT05398952). Clinical, laboratory, and CMR findings were recorded. Patients with abnormal CMR results were classified into isolated chronic pericardial (with/without pleural) effusion, isolated cardiac function impairment, or both (myopericarditis) groups. Medical treatment included a nonsteroidal anti-inflammatory agent (NSAID) for pericardial effusion and a condition-adapted maximal dose of heart failure (HF) treatment. Three months after medical therapy, clinical assessment and CMR were repeated in 82 patients. Laboratory analyses revealed normal hematological, inflammatory, coagulation, and cardiac biomarkers. CMR abnormalities were found in 155 patients (55.8%). Condition-adapted HF treatment led to a significant increase in the left ventricular ejection fraction (LVEF) in patients with initially reduced LVEF (from 49 ± 5% to 56 ± 4%, p = 0.009, n = 25). Low-moderate doses of NSAIDs for 3 months significantly reduced pericardial effusion (from 4/3;5.75/mm to 2/0;3/mm, median/interquartile ranges/p < 0.001, n = 51). Clinical symptoms improved markedly with a decrease in CMR abnormalities, which might be attributed to the maintenance of NSAID and HF medical treatment for PASC-CVS.

Causal relationship between COVID-19 and myocarditis or pericarditis risk: a bidirectional Mendelian randomization study

Background & aims

Coronavirus disease 2019 (COVID-19) is strongly associated with myocarditis or pericarditis risk in observational studies, however, there are still studies that do not support the above conclusion. Whether the observed association reflects causation needs to be confirmed. We performed a bidirectional Mendelian randomization (MR) study to assess the causal relationship of COVID-19, which was divided into three groups, namely severe COVID-19, hospitalized COVID-19, and COVID-19 infection, measured by myocarditis or pericarditis.

Methods

We extracted summary genome-wide association statistics for the severe COVID-19 (case: 13,769, control: 1,072,442), hospitalized COVID-19 (case: 32,519, control: 2,062,805), COVID-19 infection (case: 122,616, control: 2,475,240), myocarditis (case 1,521, control 191,924), and pericarditis (case 979, control 286,109) among individuals of European ancestry. Independent genetic variants that exhibited a significant association with each phenotype at the genome-wide level of significance were utilized as instrumental variables. Estimation of the causal effect was mainly performed using the random effects inverse-variance weighted method (IVW). Additionally, other tests such as MR-Egger intercept, MR-PRESSO, Cochran's Q-test, "Leave-one-out", and funnel plots were conducted to assess the extent of pleiotropy and heterogeneity.

Results

Non-associations in the IVW and sensitivity analyses were observed for COVID-19 with myocarditis or pericarditis. Severe COVID-19 was not associated with myocarditis [odds ratio (OR), 1.00; 95% confidence interval (CI), 0.89-1.12; P = 0.99], pericarditis (OR = 0.90, 95% CI, 0.78-1.04, P = 0.17). Similar results can be observed in hospitalized COVID-19, and COVID-19 infection. At the same time, null associations were observed for myocarditis or pericarditis with COVID-19 traits in the reverse direction. The main results are kept stable in the sensitivity analysis.

Conclusion

There is no evidence that COVID-19 is independently and causally associated with myocarditis or pericarditis.

Lessons Learnt from Case Series of Out-of-hospital Cardiac Arrest and Unexpected Death after COVID-19 Vaccination

Vaccination against COVID-19 has raised concerns about myocarditis in young men, as out-of-hospital cardiac arrest (OHCA) or sudden death after vaccination has been reported sporadically. Common features of these cases are occurrence in young men, within a few weeks after vaccination, in patients with no structural heart diseases. Cases of unexplained nocturnal death showed fibrotic or hypertrophied myocardium, and one case of OHCA presented ventricular fibrillation (VF) triggered by a prominent J wave on an automated external defibrillator and histopathologic findings compatible with myocarditis. Both myocarditis and J waves are prevalent in young men, and these cases imply that myocarditis augments J waves, which trigger VFs, and primary electrical disorders are a leading cause of death. To prevent such issues, artificial intelligence (AI)-assisted interpretation of historical electrocardiogram findings may help predict future J wave formation leading to VF, as digital electrocardiogram (ECG) findings are well suited for AI interpretation.

Assessing risk of major adverse cardiac event among COVID-19 patients using HEART score

Coronavirus disease 2019 (COVID-19) is known to be associated with cardiovascular complications, but whether the current validated HEART score for chest pain is still applicable for these patients is unknown. This study aims to identify the impact and association of COVID-19 co-infection in patients presenting with chest pain and a calculated HEART score to the emergency departments (ED) with 30-day of major adverse cardiac event (MACE). This is a multicenter, retrospective observational study that included adult (age ≥ 18 years) patients visiting 13 different EDs with chest pain and evaluated using a HEART score. The primary outcome was the percentage of 30-day MACE, which included acute myocardial infarction, emergency percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or death among patients who presented with chest pain and had COVID-19 co-infection. The sensitivity and specificity of the HEART score among COVID-19 co-infection for MACE were assessed by the receiver operating curve (ROC). We analyzed records of 46,210 eligible patients, in which 327 (0.7%) patients were identified as infected with COVID-19. Patients with COVID-19 had higher mean total HEART score of 3.3 (1.7), compared to patients who did not have COVID-19 (3.1, SD 1.8, P = 0.048). The rate of MACE was similar between both groups. There were only 2 (0.6%) COVID-19 patients who had MACE, compared to 504 (1.1%) patients in control group. Total HEART score was associated with an area under the ROC (AUROC) of 0.99, while the control group's was 0.78. History was associated with high AUROC in both COVID-19 (0.74) and control groups (0.76). Older age in COVID-19 had higher AUROC (0.89) than control patients (0.63). Among patients presenting to the ED with chest pain and having COVID-19 infection, HEART score had predictive capability for MACE, similar to patients without COVID-19 infection. Further studies with more COVID-19 patients are still necessary to confirm our observation.

Incidence and Impact of Acute Pericarditis in Hospitalized Patients With COVID-19

Background Acute pericarditis (AP) is considered a cardiovascular complication in patients with COVID-19. We aimed to ass-ess the incidence, associated complications, and clinical impact of AP on hospitalized patients with COVID-19. Methods and Results In this retrospective cohort study, International Classification of Diseases, Tenthth Revision, Clinical Modification (ICD-10) codes were used to identify patients with COVID-19 with or without AP in the National Inpatient Sample 2020 database. We compared outcomes between AP and non-AP groups before and after propensity-score matching for patient and hospital demographics and relevant comorbidities. A total of 211 619 patients with a primary diagnosis of COVID-19 were identified, including 983 (0.46%) patients who had a secondary diagnosis of AP. Before matching, patients with COVID-19 with AP were younger (59.93±19.24 years old versus 64.29±16.82 years old) and more likely to have anemia (40.5% versus 19.9%), cancer (6.7% versus 3.6%), and chronic kidney disease (29.3% versus 19.6%) (all P<0.05). After matching, patients with COVID-19 with AP (n=980), when compared with the matched non-AP group (n=2936), had higher rates of mortality (21.3% versus 11.1%, P<0.001), cardiac arrest (5.0% versus 2.6%, P<0.001), cardiogenic shock (4.2% versus 0.5%, P<0.001), ventricular arrhythmia (4.7% versus 1.9%, P<0.001), acute kidney injury (38.3% versus 28.9%, P<0.001), acute congestive heart failure (14.3% versus 4.8%, P<0.001), and longer length of stay (7.00±10.00 days versus 5.00±7.00 days, P<0.001) and higher total charges ($75066.5±$130831.3 versus $44824.0±$63660.5, P<0.001). Conclusions In hospitalized patients with COVID-19, AP is a rare but severe in-hospital complication and is associated with worse in-hospital outcomes.

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment

PURPOSE OF REVIEW

The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

RECENT FINDINGS

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on Emergency Patients Hospitalized With Cardiocerebrovascular Diseases in Osaka Prefecture, Japan - A Population-Based Study

BACKGROUND

Little is known about the transport and outcomes of emergency patients with cardiocerebrovascular diseases in Japan before and during the COVID-19 pandemic.

METHODS AND RESULTS

Data were extracted from a population-based registry in Osaka, Japan, from 2019 to 2021. There were almost no differences in the numbers of emergency patients hospitalized with myocardial infarction, stroke, or heart failure or their deaths. However, the number of cases of difficulty obtaining patient acceptance by hospitals increased in 2020 and 2021 compared with 2019.

CONCLUSIONS

The numbers of emergency patients hospitalized with cardiocerebrovascular diseases and their deaths in Osaka were not affected by the COVID-19 epidemic.

COVID-19 Associated Myocarditis: Prevalence, Pathophysiology, Diagnosis, and Management

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a pandemic and affected public health greatly. While COVID-19 primarily damages the lungs, leading to cough, sore throat, pneumonia, or acute respiratory distress syndrome, it also infects other organs and tissues, including the cardiovascular system. In particular, myocarditis is a well-recognized severe complication of COVID-19 infection and could result in adverse outcomes. Angiotensin-Converting Enzyme2 is thought to play a pivotal role in SARS-CoV-2 infection, and immune overresponse causes overwhelming damage to the host's myocardium. Direct viral infection and injury do take a part as well, but more evidence is needed to strengthen this proposal. The clinical abnormalities include elevated cardiac biomarkers and electrocardiogram changes and impaired cardiac function that might be presented in echocardiography and cardiovascular magnetic resonance imaging. If necessary, the endomyocardial biopsy would give more forceful information to diagnosis and aid in treatment. Comparisons between COVID-19 myocarditis and other viral myocarditis are also discussed briefly.

Bacterial endocarditis following COVID-19 infection: two case reports

BACKGROUND

COVID-19, an emerging disease raised as a pandemic, urgently needed treatment choices. Some options have been confirmed as lifesaving treatments, but long-term complications must be clearly illustrated. Bacterial endocarditis is a less frequent disease among patients infected with SARS_COV_2 compared to other cardiac comorbidities in these patients. This case report discusses bacterial endocarditis as a potential adverse effect after administering tocilizumab, corticosteroids, and COVID-19 infection.

CASE PRESENTATION

In the first case, a 51-year-old Iranian female housewife was admitted to the hospital with fever, weakness, and monoarthritis symptoms. The second case is a 63-year-old Iranian woman who is a housewife admitted with weakness, shortness of breath, and extreme sweating. Both cases tested positive for Polymerase chain reaction (PCR) less than one month ago and were treated with tocilizumab and corticosteroid. Both patients were suspected of infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the blood cultures of both patients. The diagnosis of endocarditis is confirmed for both cases. Cases are subjected to open-heart surgery, a mechanical valve is placed, and they are treated with medication. In subsequent visits, their condition was reported to be improving.

CONCLUSION

Adjacent to cardiovascular inclusion as COVID-19 disease complications, secondary infection taken after the organisation of immunocompromising specialists can result in basic maladies and conditions counting infective endocarditis.

Comparative Study of the Myocardium of Patients from Four COVID-19 Waves

BACKGROUND

Few studies have compared COVID-19 patients from different waves. This study aims to conduct a clinical and morphological analysis of patients who died from COVID-19 during four waves.

METHODS

The study involved 276 patients who died from COVID-19 during four waves, including 77 patients in the first wave, 119 patients in the second wave, and 78 patients in the third wave. We performed a histological examination of myocardium samples from autopsies and additionally analyzed the samples by PCR. We conducted immunohistochemistry of the myocardium for 21 samples using antibodies against CD3, CD45, CD8, CD68, CD34, Ang1, VWF, VEGF, HLA-DR, MHC1, C1q, enteroviral VP1, and SARS-CoV-2 spike protein. We also did immunofluorescent staining of three myocardial specimens using VP1/SARS-CoV-2 antibody cocktails. Further, we ran RT-ddPCR analysis for 14 RNA samples extracted from paraffin-embedded myocardium. Electron microscopic studies of the myocardium were also performed for two samples from the fourth wave.

RESULTS

Among the 276 cases, active myocarditis was diagnosed in 5% (15/276). Of these cases, 86% of samples expressed VP1, and individual cells contained SARS-CoV-2 spike protein in 22%. Immunofluorescence confirmed the co-localization of VP1 and SARS-CoV-2 spike proteins. ddPCR did not confidently detect SARS-CoV-2 RNA in the myocardium in any myocarditis cases. However, the myocardium sample from wave IV detected a sub-threshold signal of SARS-CoV-2 by qPCR, but myocarditis in this patient was not confirmed. Electron microscopy showed several single particles similar to SARS-CoV-2 virions on the surface of the endothelium of myocardial vessels. A comparison of the cardiovascular complication incidence between three waves revealed that the incidence of hemorrhage (48 vs. 24 vs. 17%), myocardial necrosis (18 vs. 11 vs. 4%), blood clots in the intramural arteries (12 vs. 7 vs. 0%), and myocarditis (19 vs. 1 vs. 6%) decreased over time, and CD8-T-killers appeared. Immunohistochemistry confirmed the presence of endotheliitis in all 21 studied cases.

CONCLUSIONS

This study compared myocardial damage in patients who died during three COVID-19 waves and showed a decrease in the incidence of endotheliitis complications (thrombosis, hemorrhage, necrosis) and myocarditis over time. However, the connection between myocarditis and SARS-CoV-2 infection remains unproven.

In-Hospital Outcomes of COVID-19 Associated Myocarditis (from a Nationwide Inpatient Sample Database Study)

The prevalence of COVID-19 infection-related myocarditis, its in-hospital cardiovascular outcomes, and its impact on hospital cost and stay at national level are not well studied in the literature. The Nationwide Inpatient Sample Database from 2020 was queried to identify patients with COVID-19 and myocarditis versus those without myocarditis. Cardiovascular outcomes and resource utilization were studied among cohorts with COVID-19, with and without myocarditis, using descriptive statistics, multivariate regression matching, and propensity score matching using STATA version 17. Of 1,678,995 patients, 3,565 (0.21%) had COVID-19 with myocarditis, and 1,675,355 (99.78%) had COVID-19 without myocarditis. On multivariate regression analysis, we found higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.27 to 1.9) in patients with myocarditis than in those without myocarditis, in addition to higher odds of major adverse cardiovascular and cerebrovascular events (aOR 3.54, 95% CI 2.8 to 4.4), acute kidney injury (aOR 1.29, 95% CI 1.27 to 1.9), heart failure (aOR 2.77, 95% CI 2.3 to 3.4), cardiogenic shock (aOR 10.2, 95% CI 7.9 to 13), myocardial infarction (aOR 5.74, 95% CI 4.5 to 7.3), and use of mechanical circulatory support (aOR 2.81, 95% CI 1.6 to 4.9). The propensity-matched cohort also favored similar outcomes. In conclusion, patients with COVID-19 and myocarditis had worse clinical outcomes, having a higher rate of in-hospital mortality, major adverse cardiovascular and cerebrovascular events with longer length of hospital stay, and higher hospitalization costs. Large prospective trials are necessary to validate these findings with diagnostic measures, including biopsy and cardiac magnetic resonance imaging for the extent of myocardial involvement.

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus in an immunocompetent adult after COVID-19 pneumonia: a case report

Background

SARS-CoV-2 has been implicated in many cardiac pathologies, manifesting mainly as acute. However, acute purulent pericarditis is exceedingly rare in the antibiotic era. Though, few studies have associated it with long-COVID, prompt recognition and treatment are crucial.

Case summary

A 61-year-old immunocompetent woman presented with a left lower limb pitting oedema 1 month after COVID-19 pneumonia. Following clinical, laboratory, and imaging work-up, the patient was found to have deep vein thrombosis of the anterior and posterior tibial and gastrocnemius veins. Owning to persistent sinus tachycardia, an additional work-up was performed, which revealed a large pericardial effusion. Pericardiocentesis drained the frank pus, and subsequently, empirical antibiotics therapy was initiated. Pericardial fluid cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). Following the antibiotic treatment with cloxacillin 6 × 2 g IV for 6 weeks, the patient fully recovered.

Discussion

Herein, we report a rare case of bacterial pericarditis caused by MSSA 1 month after COVID-19 pneumonia. Additionally, this condition may arise as a result of immunosuppressive treatment with glucocorticoids during and after COVID-19 pneumonia. However, the causal association has not yet been confirmed.

Positive Predictive Value of ICD-10-CM Codes for Myocarditis in Claims Data: A Multi-Institutional Study in Taiwan

Purpose

The validity of the diagnosis codes to identify myocarditis cases in healthcare databases research remains unclear, and this study aimed to determine the coding accuracy of myocarditis in Taiwan.

Methods

We conducted a cross-sectional study based on Taiwan's largest multi-institutional healthcare system to identify inpatients newly diagnosed with ICD-10-CM myocarditis codes at discharge between January 1st, 2017 and March 31st, 2022. We ascertained the myocarditis diagnosis by a gold standard biopsy or by review of electronic medical records, and the positive predictive values (PPV) with 95% confidence intervals (CI) of the ICD-10-CM codes for myocarditis were determined.

Results

We included a total of 498 inpatients (mean age: 33.8 years old; female: 38.8%) with new myocarditis diagnosis at discharge. Codes I409 (30.1%) and I514 (45.4%) constituted the majority of myocarditis diagnostic codes in any coding position, and the overall PPV of the myocarditis codes was 73.5% (95% CI: 69.6-77.4%). However, the highest PPV (96.6%) for myocarditis diagnosis was noted with code I409 as the primary diagnosis. We found 132 inpatients (26.5%) who were false-positive myocarditis cases, identified by the ICD-10-CM codes, and potential reasons for misclassification included other inflammation diseases (n=35, 26.5%), pre-existing heart failure (n= 25, 18.9%) and acute myocardial infarction (n=16, 12.1%).

Conclusion

The PPV of ICD-10-CM codes for myocarditis in Taiwan was acceptable, but some other inflammation diseases and pre-existing heart diseases may be falsely coded as myocarditis. Our results may serve future secondary database studies as a fundamental reference on the validity of myocarditis diagnosis codes.

Case report: Electrocardiographic changes in pembrolizumab-induced fatal myocarditis

Immune checkpoint inhibitor (ICI)-induced myocarditis is rare but fatal. Because of the rapid course of ICI-induced myocarditis, understanding of clinical course is only possible through information from case reports. We report a case of pembrolizumab-induced myocarditis in which we were able to document the course of electrocardiographic changes from onset to death. A 58-year-old woman with stage IV lung adenocarcinoma, who had completed her first cycle of pembrolizumab, carboplatin, and pemetrexed, was admitted with pericardial effusion. She underwent pericardiocentesis after admission. A second cycle of chemotherapy was administered 3 weeks after the first cycle. Twenty-two days after admission, she developed a mild sore throat and tested positive for SARS-CoV-2 antigen. She was diagnosed with mild coronavirus disease 2019 (COVID-19), isolated, and treated with sotrovimab. Thirty-two days after admission, an electrocardiogram showed monomorphic ventricular tachycardia (VT). Suspecting myocarditis caused by pembrolizumab, the patient was started on daily methylprednisolone after coronary angiography and endocardial biopsy. Eight days after the start of methylprednisolone administration, she was considered to have passed the acute stage. However, four days later, R-on-T phenomenon triggered polymorphic VT and she died. The impact of viral infections such as COVID-19 on patients be treated with immune checkpoint inhibitors is still unknown and we need to be careful with systemic management after viral infections.

Targeting regulatory T cells for cardiovascular diseases

Cardiovascular diseases (CVDs) are the leading cause of death and disability worldwide. The CVDs are accompanied by inflammatory progression, resulting in innate and adaptive immune responses. Regulatory T cells (Tregs) have an immunosuppressive function and are one of the subsets of CD4⁺T cells that play a crucial role in inflammatory diseases. Whether using Tregs as a biomarker for CVDs or targeting Tregs to exert cardioprotective functions by regulating immune balance, suppressing inflammation, suppressing cardiac and vascular remodeling, mediating immune tolerance, and promoting cardiac regeneration in the treatment of CVDs has become an emerging research focus. However, Tregs have plasticity, and this plastic Tregs lose immunosuppressive function and produce toxic effects on target organs in some diseases. This review aims to provide an overview of Tregs' role and related mechanisms in CVDs, and reports on the research of plasticity Tregs in CVDs, to lay a foundation for further studies targeting Tregs in the prevention and treatment of CVDs.

COVID-19 Associated Myocarditis Clinical Outcomes among Hospitalized Patients in the United States: A Propensity Matched Analysis of National Inpatient Sample

Coronavirus-19 (COVID-19), preliminarily a respiratory virus, can affect multiple organs, including the heart. Myocarditis is a well-known complication among COVID-19 infections, with limited large-scale studies evaluating outcomes associated with COVID-19-related Myocarditis. We used the National Inpatient Sample (NIS) database to compare COVID-19 patients with and without Myocarditis. A total of 1,659,040 patients were included in the study: COVID-19 with Myocarditis (n = 6,455, 0.4%) and COVID-19 without Myocarditis (n = 1,652,585, 99.6%). The primary outcome was in-hospital mortality. Secondary outcomes included mechanical ventilation, vasopressor use, sudden cardiac arrest, cardiogenic shock, acute kidney injury requiring hemodialysis, length of stay, health care utilization costs, and disposition. We conducted a secondary analysis with propensity matching to confirm results obtained by traditional multivariate analysis. COVID-19 patients with Myocarditis had significantly higher in-hospital mortality compared to COVID-19 patients without Myocarditis (30.5% vs. 13.1%, adjusted OR: 3 [95% CI 2.1-4.2], p < 0.001). This cohort also had significantly increased cardiogenic shock, acute kidney injury requiring hemodialysis, sudden cardiac death, required more mechanical ventilation and vasopressor support and higher hospitalization cost. Vaccination and more research for treatment strategies will be critical for reducing worse outcomes in patients with COVID-19-related Myocarditis.

Case report: Endovascular embolization of a cerebral pseudoaneurysm caused by SARS-CoV2 infection

Background

Severe COVID-19 has been shown to produce convulsions, encephalitis, Guillain-Barré syndrome, or cerebrovascular disease. However, only 4 case reports described subarachnoid or brain hemorrhage caused by ruptured cerebral aneurysms or pseudoaneurysms in patients with COVID-19. Cerebral pseudoaneurysms represent <1% of all intracranial aneurysms and have been related to radiation therapy, vasculitis, rupture of true saccular aneurysms, arteriovenous malformations, and infections by bacteria and viruses, such as Epstein-Bar and Herpes virus.

Case presentation

A 28-year-old Caucasian woman, with no medical history of interest and completely vaccinated against SARS-CoV-2, was admitted to Neurology due to progressive tetraparesis with areflexia, a cough, and a fever of 38°C. SARS-CoV2 PCR was positive while lumbar puncture, blood tests, and electromyogram showed criteria for Guillain-Barré syndrome. Despite the treatment, the patient developed dyspnea and tetraplegia requiring invasive mechanical ventilation. There was motor neurological improvement but a decreased level of consciousness was observed on day 13. A brain CT scan demonstrated an acute haematoma and cerebral arteriography showed a 4-mm pseudoaneurysm located in a branch of the left middle cerebral artery. Given the high risk of rebleeding, endovascular treatment was decided upon. Therefore, complete embolization of the pseudoaneurysm was carried out by using the synthetic glue N-butyl-cyanocrylate. Two days later, the patient was clinically and neurologically recovered and was discharged. Lastly, a new angiography showed no evidence of the pseudoaneurysm 3-weeks later.

Conclusions

We report, for the first time, a patient suffering a severe immune reaction caused by SARS-CoV2 infection and developing a cerebral pseudoaneurysm treated with endovascular embolization without complications.

Incidence and Prevalence of Cardiac Arrhythmias in Pericardial Syndromes

Arrhythmias in pericardial syndromes have been poorly investigated and available data are mainly obtained from relevant studies however having different endpoints from arrhythmias. Thus, the incidence and prevalence of any type of arrhythmias may be actually higher than generally considered. Atrial arrhythmias, mainly atrial fibrillation and flutter have been reported as the most common rhythm disturbances in the setting of acute pericarditis. Concerning pathophysiology of atrial arrhythmias, in contrast to earlier hypothesis that they occur exclusively in the presence of an underlying structural heart disease, recent data support an arrhythmogenic potential of acute pericardial inflammation regardless of the presence of heart disease. In cases of myopericarditis, namely primarily pericarditis with evidence of myocardial involvement (i.e., troponin elevation without however overt left ventricular dysfunction and/or segmental wall motion abnormalities), ventricular arrhythmias appear to prevail. With reference to the rest of pericardial syndromes data on arrhythmias development are even more sparce. In particular, in constrictive pericarditis atrial tachyarrhythmias are the most commonly detected and seem to be related to disease severity and possibly to the underlying etiology. In this review we have summarized the available information on the incidence and prevalence of arrhythmias in pericardial syndromes. We wish to emphasize that the clinical significance of arrhythmias in this setting in terms of prognosis and optimal medical treatment (including need and safety of anticoagulation in atrial fibrillation/flutter complicating acute pericarditis), should be further investigated.

Hospital Outcomes Among COVID-19 Hospitalizations With Myocarditis from the California State Inpatient Database

Many case reports have indicated that myocarditis could be a prognostic factor for predicting morbidity and mortality among patients with COVID-19. In this study, using a large database we examined the association between myocarditis among COVID-19 hospitalizations and in-hospital mortality and other adverse hospital outcomes. The present study was a retrospective analysis of data collected in the California State Inpatient Database during 2020. All hospitalizations for COVID-19 were included in the analysis and grouped into those with and without myocarditis. The outcomes were in-hospital mortality, cardiac arrest, cardiogenic shock, mechanical ventilation, and acute respiratory distress syndrome. Propensity score matching, followed by conditional logistic regression, was performed to find the association between myocarditis and outcomes. Among 164,417 COVID-19 hospitalizations, 578 (0.4%) were with myocarditis. After propensity score matching, the rate of in-hospital mortality was significantly higher among COVID-19 hospitalizations with myocarditis (30.0% vs 17.5%, p <0.001). Survival analysis with log-rank test showed that 30-day survival rates were significantly lower among those with myocarditis (39.5% vs 46.3%, p <0.001). Conditional logistic regression analysis showed that the odds of cardiac arrest (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.16 to 3.14), cardiogenic shock (OR 4.13, 95% CI 2.14 to 7.99), mechanical ventilation (OR 3.30, 95% CI 2.47 to 4.41), and acute respiratory distress syndrome (OR 2.49, 95% CI 1.70 to 3.66) were significantly higher among those with myocarditis. Myocarditis was associated with greater rates of in-hospital mortality and adverse hospital outcomes among patients with COVID-19, and early suspicion is important for prompt diagnosis and management.

Myocarditis associated with COVID-19 and its vaccines - a systematic review

Since the beginning of the COVID-19 (Coronavirus Disease of 2019) pandemic, myocarditis has received much attention and controversy as one of the more worrisome cardiovascular complications. After the availability of highly effective COVID-19 mRNA vaccines in late 2020, myocarditis was also appreciated as an important vaccine-related adverse event. Though the overall frequency of clinically evident viral myocarditis is rare in the general population, young males show a higher predilection for COVID vaccine-induced myocarditis. The severity of COVID-19 viral myocarditis is variable, ranging from very mild to severe, while vaccine-induced myocarditis is usually mild, and rarely a severe or fatal disease. The diagnosis of either COVID-19 or vaccine-induced myocarditis is based on typical clinical features, laboratory investigations, and imaging, preferably with cardiac magnetic resonance. The management of COVID-19 myocarditis is supportive care for mild or moderate disease. For the rare patient who develops severe disease, advanced heart failure therapies such as mechanical circulatory support devices may have to be employed and can be lifesaving. Avoidance of strenuous exercise during the bout of myocarditis and its recovery phase is important. Despite the small but finite risk of vaccine-induced myocarditis, the benefits of protection against COVID-19 disease and its attendant complications far outweigh the risks.

Myocarditis in SARS-CoV-2 infection vs. COVID-19 vaccination: A systematic review and meta-analysis

Background

This study aimed to compare the incidence of myocarditis in COVID-19 vaccines and in severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection groups.

Methods

Electronic databases (MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the WHO Global Literature on Coronavirus Disease) and trial registries were searched up to May 2022, for randomized controlled trials and observational cohort studies reporting the risk of myocarditis associated with the COVID-19 vaccines and the risk associated with SARS-CoV-2 infection. We estimated the effect of COVID-19 infection and vaccines on rates of myocarditis by random-effects meta-analyses using the generic inverse variance method. Meta-regression analyses were conducted to assess the effect of sex and age on the incidence of myocarditis.

Results

We identified 22 eligible studies consisting of 55.5 million vaccinated cohorts and 2.5 million in the infection cohort. The median age was 49 years (interquartile range (IQR): 38–56), and 49% (IQR: 43 to 52%) were men. Of patients diagnosed with myocarditis (in both vaccination and COVID-19 cohort) 1.07% were hospitalized and 0.015% died. The relative risk (RR) for myocarditis was more than seven times higher in the infection group than in the vaccination group [RR: 15 (95% CI: 11.09–19.81, infection group] and RR: 2 (95% CI: 1.44-2.65, vaccine group). Of patients who developed myocarditis after receiving the vaccine or having the infection, 61% (IQR: 39–87%) were men. Meta-regression analysis indicated that men and younger populations had a higher risk of myocarditis. A slow decline in the rates of myocarditis was observed as a function of time from vaccination. The risk of bias was low.

Conclusion

In this systematic review and meta-analysis, we found that the risk of myocarditis is more than seven fold higher in persons who were infected with the SARS-CoV-2 than in those who received the vaccine. These findings support the continued use of mRNA COVID-19 vaccines among all eligible persons per CDC and WHO recommendations.

Pericardial Involvement in Severe COVID-19 Patients

Background and Objectives: SARS-CoV-2 has an extensive tissue tropism due to its ability to attach to the surfaces of cells through different receptors, leading to systemic complications. In this article, we aim to present the prevalence of pericardial effusions in patients with severe COVID-19, to identify the risk factors/predictors for pericardial involvement, and to evaluate its impact on overall mortality. Materials and Methods: We enrolled 100 patients with severe COVID-19 in our observational cohort study and divided them in two groups: Group A (27 patients with pericardial effusion) and Group B (73 patients without pericardial effusion). We recorded demographic and lifestyle parameters, anthropometric parameters, clinical parameters, inflammation markers, respiratory function parameters, complete blood count, coagulation parameters, and biochemical serum parameters. All patients were evaluated by computer tomography scans within 48 h of admission. Results: The median age was 61 years in both groups and the male/female ratio was 3.5 vs. 2.8 in Group A vs. Group B. We identified mild pericardial effusion (3–4 mm) in 62.9% patients and moderate pericardial effusion (5–9 mm) in 37.1% patients, with a median value of 4 [3;6] mm. The patients with pericardial effusion presented with higher percentages of obesity, type-2 diabetes mellitus, arterial hypertension, and congestive heart failure, without statistical significance. Increased values in cardiac enzymes (myoglobin, CK, CK-MB) and LDH were statistically associated with pericardial effusion. The overall mortality among the participants of the study was 24% (24 patients), 33.3% in Group A and 20.8% in Group B. Conclusions: Pericardial effusion has a high prevalence (27%) among patients with severe forms of COVID-19 and was associated with higher mortality. Pericardial effusion in our study was not associated with the presence of comorbidities or the extent of lung involvement. Overall mortality was 60% higher in patients with pericardial effusion.

A Bayesian network analysis quantifying risks versus benefits of the Pfizer COVID-19 vaccine in Australia

The Pfizer COVID-19 vaccine is associated with increased myocarditis incidence. Constantly evolving evidence regarding incidence and case fatality of COVID-19 and myocarditis related to infection or vaccination, creates challenges for risk-benefit analysis of vaccination. Challenges are complicated further by emerging evidence of waning vaccine effectiveness, and variable effectiveness against variants. Here, we build on previous work on the COVID-19 Risk Calculator (CoRiCal) by integrating Australian and international data to inform a Bayesian network that calculates probabilities of outcomes for the delta variant under different scenarios of Pfizer COVID-19 vaccine coverage, age groups (≥12 years), sex, community transmission intensity and vaccine effectiveness. The model estimates that in a population where 5% were unvaccinated, 5% had one dose, 60% had two doses and 30% had three doses, there was a substantially greater probability of developing (239–5847 times) and dying (1430–384,684 times) from COVID-19-related than vaccine-associated myocarditis (depending on age and sex). For one million people with this vaccine coverage, where transmission intensity was equivalent to 10% chance of infection over 2 months, 68,813 symptomatic COVID-19 cases and 981 deaths would be prevented, with 42 and 16 expected cases of vaccine-associated myocarditis in males and females, respectively. These results justify vaccination in all age groups as vaccine-associated myocarditis is generally mild in the young, and there is unequivocal evidence for reduced mortality from COVID-19 in older individuals. The model may be updated to include emerging best evidence, data pertinent to different countries or vaccines and other outcomes such as long COVID.

COVID-19 vaccination in pregnancy

Despite a recent endorsement from official and professional bodies unequivocally recommending COVID-19 vaccination, vaccine hesitancy among pregnant people remains high. The accumulated evidence demonstrates that pregnant people are a special risk group for COVID-19, with an increased risk of intensive care unit admission, extracorporeal membranous oxygenation requirement, preterm birth, and perinatal death. These risks are further increased with some variants of concern, and vaccination of pregnant people reduces the COVID-19-related increase in maternal or fetal morbidity. Data from more than 180,000 vaccinated persons show that immunization against COVID-19 with an mRNA vaccine is safe for pregnant people. Many observational studies comparing perinatal outcomes between vaccinated and unvaccinated pregnant people have had reassuring findings and did not demonstrate harmful effects on pregnancy or the newborn. Immunization with mRNA vaccines does not increase the risk of miscarriage, preterm delivery, low birthweight, maternal or neonatal intensive care unit admission, fetal death, fetal abnormality, or pulmonary embolism. Moreover, observational data corroborate the findings of randomized trials that mRNA vaccination is highly effective at preventing severe SARS-CoV-2 infection in pregnant people, emphasizing that the potential maternal and fetal benefits of vaccination greatly outweigh the potential risks of vaccination. Ensuring pregnant people have unrestricted access to COVID-19 vaccination should be a priority in every country worldwide.

Parametric Mapping Cardiac Magnetic Resonance Imaging for the Diagnosis of Myocarditis in Children in the Era of COVID-19 and MIS-C

Myocarditis comprises many clinical presentations ranging from asymptomatic to sudden cardiac death. The history, physical examination, cardiac biomarkers, inflammatory markers, and electrocardiogram are usually helpful in the initial assessment of suspected acute myocarditis. Echocardiography is the primary tool to detect ventricular wall motion abnormalities, pericardial effusion, valvular regurgitation, and impaired function. The advancement of cardiac magnetic resonance (CMR) imaging has been helpful in clinical practice for diagnosing myocarditis. A recent Scientific Statement by the American Heart Association suggested CMR as a confirmatory test to diagnose acute myocarditis in children. However, standard CMR parametric mapping parameters for diagnosing myocarditis are unavailable in pediatric patients for consistency and reliability in the interpretation. The present review highlights the unmet clinical needs for standard CMR parametric criteria for diagnosing acute and chronic myocarditis in children and differentiating dilated chronic myocarditis phenotype from idiopathic dilated cardiomyopathy. Of particular relevance to today’s practice, we also assess the potential and limitations of CMR to diagnose acute myocarditis in children exposed to severe acute respiratory syndrome coronavirus-2 infections. The latter section will discuss the multi-inflammatory syndrome in children (MIS-C) and mRNA coronavirus disease 19 vaccine-associated myocarditis.

A Deep Learning Algorithm for Detecting Acute Pericarditis by Electrocardiogram

(1) Background: Acute pericarditis is often confused with ST-segment elevation myocardial infarction (STEMI) among patients presenting with acute chest pain in the emergency department (ED). Since a deep learning model (DLM) has been validated to accurately identify STEMI cases via 12-lead electrocardiogram (ECG), this study aimed to develop another DLM for the detection of acute pericarditis in the ED. (2) Methods: This study included 128 ECGs from patients with acute pericarditis and 66,633 ECGs from patients visiting the ED between 1 January 2010 and 31 December 2020. The ECGs were randomly allocated based on patients to the training, tuning, and validation sets, at a 3:1:1 ratio. We used raw ECG signals to train a pericarditis-DLM and used traditional ECG features to train a machine learning model. A human–machine competition was conducted using a subset of the validation set, and the performance of the Philips automatic algorithm was also compared. STEMI cases in the validation set were extracted to analyze the DLM ability of differential diagnosis between acute pericarditis and STEMI using ECG. We also followed the hospitalization events in non-pericarditis cases to explore the meaning of false-positive predictions. (3) Results: The pericarditis-DLM exceeded the performance of all participating human experts and algorithms based on traditional ECG features in the human–machine competition. In the validation set, the pericarditis-DLM could detect acute pericarditis with an area under the receiver operating characteristic curve (AUC) of 0.954, a sensitivity of 78.9%, and a specificity of 97.7%. However, our pericarditis-DLM also misinterpreted 10.2% of STEMI ECGs as pericarditis cases. Therefore, we generated an integrating strategy combining pericarditis-DLM and a previously developed STEMI-DLM, which provided a sensitivity of 73.7% and specificity of 99.4%, to identify acute pericarditis in patients with chest pains. Compared to the true-negative cases, patients with false-positive results using this strategy were associated with higher risk of hospitalization within 3 days due to cardiac disorders (hazard ratio (HR): 8.09; 95% confidence interval (CI): 3.99 to 16.39). (4) Conclusions: The AI-enhanced algorithm may be a powerful tool to assist clinicians in the early detection of acute pericarditis and differentiate it from STEMI using 12-lead ECGs.

Myopericarditis following COVID-19 vaccination and non-COVID-19 vaccination: a systematic review and meta-analysis

BACKGROUND

Myopericarditis is a rare complication of vaccination. However, there have been increasing reports of myopericarditis following COVID-19 vaccination, especially among adolescents and young adults. We aimed to characterise the incidence of myopericarditis following COVID-19 vaccination, and compare this with non-COVID-19 vaccination.

METHODS

We did a systematic review and meta-analysis, searching four international databases from Jan 1, 1947, to Dec 31, 2021, for studies in English reporting on the incidence of myopericarditis following vaccination (the primary outcome). We included studies reporting on people in the general population who had myopericarditis in temporal relation to receiving vaccines, and excluded studies on a specific subpopulation of patients, non-human studies, and studies in which the number of doses was not reported. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and the intra-study risk of bias (Joanna Briggs Institute checklist) and certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluations approach) were assessed. We analysed the difference in incidence of myopericarditis among subpopulations, stratifying by the type of vaccine (COVID-19 vs non-COVID-19) and age group (adult vs paediatric). Among COVID-19 vaccinations, we examined the effect of the type of vaccine (mRNA or non-mRNA), sex, age, and dose on the incidence of myopericarditis. This study was registered with PROSPERO (CRD42021275477).

FINDINGS

The overall incidence of myopericarditis from 22 studies (405 272 721 vaccine doses) was 33·3 cases (95% CI 15·3-72·6) per million vaccine doses, and did not differ significantly between people who received COVID-19 vaccines (18·2 [10·9-30·3], 11 studies [395 361 933 doses], high certainty) and those who received non-COVID-19 vaccines (56·0 [10·7-293·7], 11 studies [9 910 788 doses], moderate certainty, p=0·20). Compared with COVID-19 vaccination, the incidence of myopericarditis was significantly higher following smallpox vaccinations (132·1 [81·3-214·6], p<0·0001) but was not significantly different after influenza vaccinations (1·3 [0·0-884·1], p=0·43) or in studies reporting on various other non-smallpox vaccinations (57·0 [1·1-3036·6], p=0·58). Among people who received COVID-19 vaccines, the incidence of myopericarditis was significantly higher in males (vs females), in people younger than 30 years (vs 30 years or older), after receiving an mRNA vaccine (vs non-mRNA vaccine), and after a second dose of vaccine (vs a first or third dose).

INTERPRETATION

The overall risk of myopericarditis after receiving a COVID-19 vaccine is low. However, younger males have an increased incidence of myopericarditis, particularly after receiving mRNA vaccines. Nevertheless, the risks of such rare adverse events should be balanced against the risks of COVID-19 infection (including myopericarditis).

FUNDING

None.

Viral Myocarditis: Classification, Diagnosis, and Clinical Implications

Myocarditis is an inflammatory disease of the myocardium with focal or diffuse involvement. Viral infections are the most common cause of myocarditis, especially in Western countries. A recent viral illness with gastroenteric or upper respiratory symptoms often precedes myocarditis. The absence of specific pathognomonic features in conjunction with the wide spectrum of clinical manifestations that range from subclinical cases to sudden cardiac death (SCD) makes myocarditis diagnosis particularly challenging. Moreover, myocarditis might represent a cause of initially unexplained dilated cardiomyopathy (DCM) and heart failure (HF), especially among children and young adults. Cardiac magnetic resonance imaging (CMR) is crucial for myocarditis diagnosis, because of its ability to detect interstitial edema during acute inflammation. Assessment of subepicardial or mid-myocardial fibrosis by late gadolinium enhancement (LGE) is typical for myocarditis. Cardiac arrhythmias are frequent events that may arise especially in more severe myocarditis cases. The most common form of arrhythmia is atrial fibrillation, followed by ventricular tachycardia. Documented arrhythmias have been reported more commonly with HIV myocarditis than other more common infections such as Adenovirus, Parvovirus B19, human Herpes virus 6, and Enterovirus. The mechanisms of arrhythmogenesis in myocardial inflammation are not fully understood; in the acute phase, the spectrum of arrhythmogenesis ranges from a direct effect on cardiomyocytes that leads to electrical instability and ion channel impairment to ischemia from coronary macro- or microvascular disease. In chronic myocarditis, instead, myocardial replacement with fibrosis promotes scar-mediated re-entrant ventricular arrhythmias. Observational data suggested the important role of CMR, with LGE being the strongest independent predictor of SCD, cardiac, and all-cause mortality. In acute myocarditis, the most common localization of subepicardial LGE dwells in the lateral wall. Patients with myocarditis that develop HF and arrhythmias usually show a larger LGE distribution involving several myocardial segments. Moreover, a mid-layer LGE in the interventricular septum is more frequent in acute myocarditis than in acute coronary syndromes cases. The risk of SCD in patients with wide areas of LGE is significant, and a shared decision-making approach is warranted. Nevertheless, there is no formal consensus about the extension of LGE to justify implantable cardioverter defibrillator (ICD) implantation in primary prevention.

Myocarditis Following COVID-19 Vaccination: A Systematic Review of Case Reports

Introduction: COVID-19, the infectious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), often presents with a spectrum of symptoms at varying levels of severity, ranging from asymptomatic patients to those with fatal complications, such as myocarditis. With increased availability of COVID-19 vaccines, the awareness of possible side effects has expanded as reports surface. This study reviewed cases of myocarditis following COVID-19 vaccination and with existing literature on COVID-19 infection-induced myocarditis to compare clinical courses and analyze possible mechanisms of action. Methods: A systematic review of literature was conducted to identify published case reports (as of February 3, 2022) pertaining to the development of myocarditis following COVID-19 vaccination with either Pfizer or Moderna for an in-depth analysis. Additional subgroup analyses were conducted based on age, past medical history, vaccine manufacturer, and dose number. Results: There were 53 eligible case reports that were included in this study. Patients were mostly male with a median age of 24 years, and the most reported symptom upon presentation was chest pain. Seventy percent of the cases involved the Pfizer vaccine with a majority of myocarditis developing subsequent to second dose. Resolution of symptoms was achieved in all but one patient. Clinical severity, as measured primarily by left ventricular ejection fraction, appeared to be worse among adult patients than pediatric, as well as for patients with comorbidities. Conclusion: This study revealed an observable association between COVID-19 vaccines and myocarditis. However, the clinical course and prognosis seem favorable and less prevalent than those conferred from natural infection.

Acute Pericarditis: Update

Purpose of Review

Since 2015, when ESC guidelines for the diagnosis and management of pericardial diseases were published, ongoing research has enhanced the current state of knowledge on acute pericarditis. This review is an update on the latest developments in this field.

Recent Findings

In recurrent acute pericarditis, autoinflammation has been included among causative mechanisms restricting the vague diagnoses of “idiopathic” pericarditis. Cardiac magnetic resonance that detects ongoing pericardial inflammation may guide treatment in difficult-to-treat patients. Development of risk scores may assist identification of patients at high risk for complicated pericarditis, who should be closely monitored and aggressively treated. Treatment with IL-1 inhibitors has been proven efficacious in recurrent forms with a good safety profile. Finally, acute pericarditis has recently attracted great interest as it has been reported among side effects post COVID-19 vaccination and may also complicate SARS-CoV-2 infection.

Summary

Recent advancements in acute pericarditis have contributed to a better understanding of the disease allowing a tailored to the individual patient approach. However, there are still unsolved questions that require further research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11886-022-01710-8.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Pericarditis following COVID-19 vaccination: Two case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness which conventionally manifests with primarily respiratory symptoms and less commonly with cardiac involvement in various forms, such as pericarditis. Myocarditis and pericarditis have been reported in a variety of live and attenuated vaccines, such as smallpox and influenza. As of October 2021, no cases of pericarditis associated with COVID-19 vaccination have been published. We present two healthy male patients who present post COVID-19 vaccination with pericarditis diagnoses.

CASE SUMMARY

A 21-year-old male with no significant past medical history presented with myalgia, chills, mild headache, and chest pain for two days. Patient received the Moderna COVID-19 vaccine the day prior to symptom onset. On presentation, electrocardiogram (ECG) revealed sinus rhythm with ST elevation, and troponin was elevated. Emergent cardiac catheterization was not significant for abnormalities. The primary diagnosis was acute pericarditis, and the patient was discharged on colchicine and indomethacin. Additionally, a 35-year-old male with no pertinent past medical history presented with fever, chills, weakness, nausea, vomiting, diarrhea, and retrosternal chest pain for three days. He received the Moderna COVID-19 vaccine four days prior to symptom onset. On presentation, troponin was elevated, and ECG revealed mild ST elevation. Left ventricular dysfunction with ejection fraction of 41% was reported on transthoracic echocardiogram. Patient was started on ibuprofen and colchicine for diagnosis of myopericarditis.

CONCLUSION

These case reports highlight a potential unintended consequence, pericarditis, associated with COVID-19 vaccination that may not warrant invasive cardiac intervention.

COVID-19-Associated Myocarditis: An Evolving Concern in Cardiology and Beyond

Simple Summary

Coronavirus disease-2019 (COVID-19) affects many organs in the body, including the heart. One complication of particular concern is inflammation of the heart muscle, called myocarditis. This paper presents updated research data on COVID-19-associated myocarditis. Specifically, we review the incidence, potential mechanisms, blood and imaging tests that can be used to detect the disease. We emphasize that, in contrast with early reports, recent data suggest that myocarditis in the setting of COVID-19 is relatively uncommon, yet infected individuals are at a substantially increased risk for poor outcomes. It is important to continue research in this area.

Abstract

The direct and indirect adverse effects of SARS-CoV-2 infection on the cardiovascular system, including myocarditis, are of paramount importance. These not only affect the disease course but also determine clinical outcomes and recovery. In this review, the authors aimed at providing an update on the incidence of Coronavirus disease-2019 (COVID-19)-associated myocarditis. Our knowledge and experience relevant to this area continues to evolve rapidly since the beginning of the pandemic. It is crucial for the scientific and medical community to stay abreast of current information. Contrasting early reports, recent data suggest that the overall incidence of SARS-CoV-2-associated myocarditis is relatively low, yet infected individuals are at a substantially increased risk. Therefore, understanding the pathophysiology and diagnostic evaluation, including the use of serum biomarkers and imaging modalities, remain important. This review aims to summarize the most recent data in these areas as they relate to COVID-19-associated myocarditis. Given its increasing relevance, a brief update is included on the proposed mechanisms of myocarditis in COVID-19 vaccine recipients.

Pericardial Involvement in Patients Hospitalized With COVID‐19: Prevalence, Associates, and Clinical Implications

Background

The scope of pericardial involvement in COVID‐19 infection is unknown. We aimed to evaluate the prevalence, associates, and clinical impact of pericardial involvement in hospitalized patients with COVID‐19.

Methods and Results

Consecutive patients with COVID‐19 underwent clinical and echocardiographic examination, irrespective of clinical indication, within 48 hours as part of a prospective predefined protocol. Protocol included clinical symptoms and signs suggestive of pericarditis, calculation of modified early warning score, ECG and echocardiographic assessment for pericardial effusion, left and right ventricular systolic and diastolic function, and hemodynamics. We identified predictors of mortality and assessed the adjunctive value of pericardial effusion on top of clinical and echocardiographic parameters. The study included 530 patients. Pericardial effusion was found in 75 (14%), but only 17 patients (3.2%) fulfilled the criteria for acute pericarditis. Pericardial effusion was independently associated with modified early warning score, brain natriuretic peptide, and right ventricular function. It was associated with excess mortality (hazard ratio [HR], 2.44; P=0.0005) in nonadjusted analysis. In multivariate analysis adjusted for modified early warning score and echocardiographic and hemodynamic parameters, it was marginally associated with mortality (HR, 1.86; P=0.06) and improvement in the model fit (P=0.07). Combined assessment for pericardial effusion with modified early warning score, left ventricular ejection fraction, and tricuspid annular plane systolic excursion was an independent predictor of outcome (HR, 1.86; P=0.02) and improved model fit (P=0.02).

Conclusions

In hospitalized patients with COVID‐19, pericardial effusion is prevalent, but rarely attributable to acute pericarditis. It is associated with myocardial dysfunction and mortality. A limited echocardiographic examination, including left ventricular ejection fraction, tricuspid annular plane systolic excursion, and assessment for pericardial effusion, can contribute to outcome prediction.

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.

Cardiac Dysfunction and Arrhythmias 3 Months After Hospitalization for COVID‐19

Background

The extent of cardiac dysfunction post‐COVID‐19 varies, and there is a lack of data on arrhythmic burden.

Methods and Results

This was a combined multicenter prospective cohort study and cross‐sectional case‐control study. Cardiac function assessed by echocardiography in patients with COVID‐19 3 to 4 months after hospital discharge was compared with matched controls. The 24‐hour ECGs were recorded in patients with COVID‐19. A total of 204 patients with COVID‐19 consented to participate (mean age, 58.5 years; 44% women), and 204 controls were included (mean age, 58.4 years; 44% women). Patients with COVID‐19 had worse right ventricle free wall longitudinal strain (adjusted estimated mean difference, 1.5 percentage points; 95% CI, −2.6 to −0.5; P=0.005) and lower tricuspid annular plane systolic excursion (−0.10 cm; 95% CI, −0.14 to −0.05; P<0.001) and cardiac index (−0.26 L/min per m²; 95% CI, −0.40 to −0.12; P<0.001), but slightly better left ventricle global strain (−0.8 percentage points; 95% CI, 0.2–1.3; P=0.008) compared with controls. Reduced diastolic function was twice as common compared with controls (60 [30%] versus 29 [15%], respectively; odds ratio, 2.4; P=0.001). Having dyspnea or fatigue were not associated with cardiac function. Right ventricle free wall longitudinal strain was worse after intensive care treatment. Arrhythmias were found in 27% of the patients, mainly premature ventricular contractions and nonsustained ventricular tachycardia (18% and 5%, respectively).

Conclusions

At 3 months after hospital discharge with COVID‐19, right ventricular function was mildly impaired, and diastolic dysfunction was twice as common compared with controls. There was little evidence for an association between cardiac function and intensive care treatment, dyspnea, or fatigue. Ventricular arrhythmias were common, but the clinical importance is unknown.

Registration

URL: http://clinicaltrials.gov. Unique Identifier: NCT04535154.

Chronic heart failure: evolution of etiology, prevalence and mortality over the past 20 years

The article is devoted to the analysis of changes in the role of causal and comorbid risk factors for two main types of heart failure with reduced and preserved ejection fraction over the previous 20 years. Within the same time interval, the dynamics of the prevalence and mortality for these clinical variants. Special attention is paid to a possible solution to the issue of the complexity of recording cases of diagnosis and treatment of chronic heart failure in outpatient and hospital practice.