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Abstract
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.
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Affiliation(s)
- DeLisa Fairweather
- Department of Cardiovascular Medicine (D.F., D.J.B., D.N.D., L.T.C.), Mayo Clinic, Jacksonville, FL
- Department of Environmental Health Sciences and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (D.F.,)
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN (D.F., D.J.B., D.N.D.)
| | - Danielle J. Beetler
- Department of Cardiovascular Medicine (D.F., D.J.B., D.N.D., L.T.C.), Mayo Clinic, Jacksonville, FL
- Mayo Clinic Graduate School of Biomedical Sciences (D.J.B., D.N.D.), Mayo Clinic, Jacksonville, FL
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN (D.F., D.J.B., D.N.D.)
| | - Damian N. Di Florio
- Department of Cardiovascular Medicine (D.F., D.J.B., D.N.D., L.T.C.), Mayo Clinic, Jacksonville, FL
- Mayo Clinic Graduate School of Biomedical Sciences (D.J.B., D.N.D.), Mayo Clinic, Jacksonville, FL
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN (D.F., D.J.B., D.N.D.)
| | - Nicolas Musigk
- Deutsches Herzzentrum der Charité, Berlin, Germany (N.M., B.H.)
| | | | - Leslie T. Cooper
- Department of Cardiovascular Medicine (D.F., D.J.B., D.N.D., L.T.C.), Mayo Clinic, Jacksonville, FL
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Batiha GES, Al-kuraishy HM, Al-Gareeb AI, Youssef FS, El-Sherbeni SA, Negm WA. A perspective study of the possible impact of obeticholic acid against SARS-CoV-2 infection. Inflammopharmacology 2023; 31:9-19. [PMID: 36484974 PMCID: PMC9735105 DOI: 10.1007/s10787-022-01111-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
The causative agent of CoV disease 2019 is a new coronavirus CoV type 2, affecting the respiratory tract with severe manifestations (SARS-CoV-2). Covid-19 is mainly symptomless, with slight indications in about 85% of the affected cases. Many efforts were done to face this pandemic by testing different drugs and agents to make treatment protocols in different countries. However, the use of these proposed drugs is associated with the development of adverse events. Remarkably, the successive development of SARS-CoV-2 variants which could affect persons even they were vaccinated, prerequisite wide search to find efficient and safe agents to face SARS-CoV-2 infection. Obeticholic acid (OCA), which has anti-inflammatory effects, may efficiently treat Covid-19. Thus, the goal of this perspective study is to focus on the possible medicinal effectiveness in managing Covid-19. OCA is a powerful farnesoid X receptor (FXR) agonist possessing marked antiviral and anti-inflammatory effects. FXR is dysregulated in Covid-19 resulting in hyper-inflammation with concurrent occurrence of hypercytokinemia. Interestingly, OCA inhibits the reaction between this virus and angiotensin-converting enzyme type 2 (ACE2) receptors. FXR agonists control the expression of ACE2 and the inflammatory signaling pathways in this respiratory syndrome, which weakens the effects of Covid-19 disease and accompanied complications. Taken together, FXR agonists like OCA may reveal both direct and indirect impacts in the modulation of immune reaction in SARS-CoV-2 conditions. It is highly recommended to perform many investigations regarding different phases of the discovery of new drugs.
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Affiliation(s)
- Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, 22511 AlBeheira Egypt
| | - Hayder M. Al-kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, ALmustansiriyia University, Baghdad, Iraq
| | - Ali I. Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, ALmustansiriyia University, Baghdad, Iraq
| | - Fadia S. Youssef
- Department of Pharmacognosy, Faculty of Pharmacy, Ain-Shams University, Abbasia, Cairo, 11566 Egypt
| | - Suzy A. El-Sherbeni
- Department of Pharmacognosy, Faculty of Pharmacy, Tanta University, Tanta, 31527 Egypt
| | - Walaa A. Negm
- Department of Pharmacognosy, Faculty of Pharmacy, Tanta University, Tanta, 31527 Egypt
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3
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Vidusa L, Kalejs O, Maca-Kaleja A, Strumfa I. Role of Endomyocardial Biopsy in Diagnostics of Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12092104. [PMID: 36140505 PMCID: PMC9497694 DOI: 10.3390/diagnostics12092104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022] Open
Abstract
Endomyocardial biopsy as the cornerstone of diagnostics has been re-evaluated throughout the years, leaving unanswered questions on the precedence of it. The reported incidence of myocarditis has increased during the pandemic of coronavirus disease 2019 (COVID-19), reinforcing discussions on appropriate diagnostics of myocarditis. By analysis of evidence-based literature published within the last demi-decade, we aimed to summarize the most recent information in order to evaluate the current role of endomyocardial biopsy in diagnostics and management of myocarditis. For the most part, research published over the last five years showed ongoing uncertainty regarding the use, informativeness, safety and necessity of performing a biopsy. Special circumstances, such as fulminant clinical course or failure to respond to empirical treatment, were reconfirmed as justified indications, with a growing applicability of non-invasive diagnostic approaches for most other cases. We concluded that endomyocardial biopsy, if performed properly and with adjunct diagnostic methods, holds a critical role for treatment correction in specific histological subtypes of myocarditis and for differential diagnosis between immune-mediated myocarditis and secondary infections due to immunosuppressive treatment. A high level of possible misdiagnosing was detected, indicating the need to review terminology used to describe findings of myocardial inflammation that did not meet Dallas criteria.
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Affiliation(s)
- Liga Vidusa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Aija Maca-Kaleja
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Ilze Strumfa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Correspondence:
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4
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Henning RJ. Cardiovascular complications of COVID-19 severe acute respiratory syndrome. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2022; 12:170-191. [PMID: 36147783 PMCID: PMC9490160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/15/2022] [Indexed: 06/16/2023]
Abstract
603,711,760 confirmed cases of COVID-19 have been reported throughout the world and 6,484,136 individuals have died from complications of COVID-19 as of September 7, 2022. Significantly, the Omicron variant has produced the largest number of COVID-19 associated hospitalizations since the beginning of the pandemic. Cardiac injury occurs in ≥20% of the hospitalized patients with COVID-19 and is associated with cardiac dysrhythmias in 17 to 44%, cardiac injury with increases in blood troponin in 22 to 40%, myocarditis in 2 to 7%, heart failure in 4 to 21%, and thromboembolic events in 15 to 39%. Risk factors for cardiac complications include age >70 years, male sex, BMI ≥30 kg/m2, diabetes, pre-existing cardiovascular disease, and moderate to severe pneumonia at hospital presentation. Patients with prior cardiovascular disease who contract COVID-19 and experience a significant increase in their blood troponin concentration are at risk for mortality rates as high as 69%. This review focuses on the prevalence, the pathophysiologic mechanisms of CoV-2 injury to the cardiovascular system and the current recommended treatments in hospitalized patients with COVID-19 in order that medical personnel can decrease the morbidity and mortality of patients with COVID-19 and effectively treat patients with Covid and post Covid syndrome.
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Affiliation(s)
- Robert J Henning
- University of South Florida 13201 Bruce B. Downs Blvd, Tampa, Florida 33612-3805, USA
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Lovell JP, Čiháková D, Gilotra NA. COVID-19 and Myocarditis: Review of Clinical Presentations, Pathogenesis and Management. Heart Int 2022; 16:20-27. [PMID: 36275349 PMCID: PMC9524641 DOI: 10.17925/hi.2022.16.1.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/21/2022] [Indexed: 08/17/2023] Open
Abstract
There are four main myocarditis presentations identified in the context of severe acute respiratory coronavirus 2 (SARS-CoV-2): myocarditis associated with acute coronavirus disease 2019 (COVID-19) infection, post-acute COVID-19 syndrome, multisystem inflammatory syndrome, and vaccination-associated myocarditis. This article reviews the clinical features and current management strategies for each of these presentations. The overall prevalence of myocarditis is considered to be rare, although accurate estimation is affected by heterogeneity in diagnostic criteria and reporting, as well as infrequent use of gold-standard diagnostic endomyocardial biopsy. Severity of disease can range from mild symptoms to fulminant myocarditis. Therapeutic interventions are typically supportive and extrapolated from treatment for non-COVID-19 viral myocarditis. Several pathogenic mechanisms for the development of myocarditis have been proposed, and ongoing research is critical for elucidating disease pathogenesis and potentially identifying therapeutic targets. The long-term cardiovascular sequelae of SARS-CoV-2 infections and associated myocarditis require further elucidation and understanding.
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Affiliation(s)
- Jana P Lovell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniela Čiháková
- Department of Pathology, Johns Hopkins University of Medicine, Baltimore, MD, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Freund O, Eviatar T, Bornstein G. Concurrent myopathy and inflammatory cardiac disease in COVID-19 patients: a case series and literature review. Rheumatol Int 2022; 42:905-912. [PMID: 35275269 PMCID: PMC8915139 DOI: 10.1007/s00296-022-05106-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/25/2022] [Indexed: 01/05/2023]
Abstract
Adult COVID-19 patients can present with acute muscle and/or cardiac involvement. Our study aims to describe the incidence and characteristics of patients with the co-occurrence of COVID-19 myopathy and inflammatory cardiac disease. We retrospectively reviewed all COVID-19 patients admitted to a large tertiary center to assess the co-occurrence of myopathy and inflammatory cardiac disease. We conducted a literature review of prior relevant case reports. There were three COVID-19 patients with concurrent involvement from our center and five cases in the published literature. Overall, mean age was 57.7 ± 16, four were females (50%) and only two patients (25%) had major relevant comorbidities. Muscle involvement included rhabdomyolysis or myositis and cardiac involvement included myocarditis or pericarditis. Most patients (75%) had no respiratory COVID-19 symptoms. Troponin and creatine phosphokinase levels were higher than twofold of the upper limit of normal for all patients. Steroids were used in the treatment of most patients (75%). All patients had a resolution or improvement of their extra-pulmonary involvement while two (25%) deteriorated due to COVID-19 pneumonia. The incidence for this co-occurrence is 0.07% among hospitalized COVID-19 patients. Patients with these rare COVID-19 simultaneous manifestations have distinct features. They are generally younger, present with extra-pulmonary symptoms and do not have severe respiratory compromise. An underdiagnosis causing treatment delay is possible. Further study is needed.
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Affiliation(s)
- Ophir Freund
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
| | - Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Gil Bornstein
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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Yazdanbakhsh M, Saghaei Dehkordi S. An Overview of Published Articles in Archives of Academic Emergency Medicine in 2021. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e18. [PMID: 35402996 PMCID: PMC8986493 DOI: 10.22037/aaem.v10i1.1555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Mehrnoosh Yazdanbakhsh
- Journal Office, Emergency Ward, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Saghaei Dehkordi
- Journal Office, Emergency Ward, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: Somayeh Saghaei Dehkordi; Emergency Ward, Shohadaye Tajrish Hospital, Shahrdari Avenue, Tajrish Square, Tehran, Iran. Tel: 00989388136564
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Parra-Lucares A, Toro L, Weitz-Muñoz S, Ramos C. Cardiomyopathy Associated with Anti-SARS-CoV-2 Vaccination: What Do We Know? Viruses 2021; 13:2493. [PMID: 34960761 PMCID: PMC8708989 DOI: 10.3390/v13122493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 02/06/2023] Open
Abstract
The SARS-CoV-2 pandemic has mobilized many efforts worldwide to curb its impact on morbidity and mortality. Vaccination of the general population has resulted in the administration of more than 6,700,000,000 doses by the end of October 2021, which is the most effective method to prevent hospitalization and death. Among the adverse effects described, myocarditis and pericarditis are low-frequency events (less than 10 per 100,000 people), mainly observed with messenger RNA vaccines. The mechanisms responsible for these effects have not been specified, considering an exacerbated and uncontrolled immune response and an autoimmune response against specific cardiomyocyte proteins. This greater immunogenicity and reactogenicity is clinically manifested in a differential manner in pediatric patients, adults, and the elderly, determining specific characteristics of its presentation for each age group. It generally develops as a condition of mild to moderate severity, whose symptoms and imaging findings are self-limited, resolving favorably in days to weeks and, exceptionally, reporting deaths associated with this complication. The short- and medium-term prognosis is favorable, highlighting the lack of data on long-term evolution, which should be determined in longer follow-ups.
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Affiliation(s)
- Alfredo Parra-Lucares
- Division of Critical Care Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- Critical Care Unit, Clinica Las Condes, Santiago 7591046, Chile
- Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Sebastián Weitz-Muñoz
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile;
| | - Cristóbal Ramos
- Department of Radiology, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile;
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Jaiswal V, Sarfraz Z, Sarfraz A, Mukherjee D, Batra N, Hitawala G, Yaqoob S, Patel A, Agarwala P, Ruchika, Sarfraz M, Bano S, Azeem N, Naz S, Jaiswal A, Sharma P, Chaudhary G. COVID-19 Infection and Myocarditis: A State-of-the-Art Systematic Review. J Prim Care Community Health 2021; 12:21501327211056800. [PMID: 34854348 PMCID: PMC8647231 DOI: 10.1177/21501327211056800] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well. COVID-19 may lead to cardiovascular injuries, resulting in myocarditis, with inflammation of the heart muscle. OBJECTIVE This systematic review collates current evidence about demographics, symptomatology, diagnostic, and clinical outcomes of COVID-19 infected patients with myocarditis. METHODS In accordance with PRISMA 2020 guidelines, a systematic search was conducted using PubMed, Cochrane Central, Web of Science and Google Scholar until August, 2021. A combination of the following keywords was used: SARS-CoV-2, COVID-19, myocarditis. Cohorts and case reports that comprised of patients with confirmed myocarditis due to COVID-19 infection, aged >18 years were included. The findings were tabulated and subsequently synthesized. RESULTS In total, 54 case reports and 5 cohorts were identified comprising 215 patients. Hypertension (51.7%), diabetes mellitus type 2 (46.4%), cardiac comorbidities (14.6%) were the 3 most reported comorbidities. Majority of the patients presented with cough (61.9%), fever (60.4%), shortness of breath (53.2%), and chest pain (43.9%). Inflammatory markers were raised in 97.8% patients, whereas cardiac markers were elevated in 94.8% of the included patients. On noting radiographic findings, cardiomegaly (32.5%) was the most common finding. Electrocardiography testing obtained ST segment elevation among 44.8% patients and T wave inversion in 7.3% of the sample. Cardiovascular magnetic resonance imaging yielded 83.3% patients with myocardial edema, with late gadolinium enhancement in 63.9% patients. In hospital management consisted of azithromycin (25.5%), methylprednisolone/steroids (8.5%), and other standard care treatments for COVID-19. The most common in-hospital complication included acute respiratory distress syndrome (66.4%) and cardiogenic shock (14%). On last follow up, 64.7% of the patients survived, whereas 31.8% patients did not survive, and 3.5% were in the critical care unit. CONCLUSION It is essential to demarcate COVID-19 infection and myocarditis presentations due to the heightened risk of death among patients contracting both myocardial inflammation and ARDS. With a multitude of diagnostic and treatment options available for COVID-19 and myocarditis, patients that are under high risk of suspicion for COVID-19 induced myocarditis must be appropriately diagnosed and treated to curb co-infections.
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Affiliation(s)
| | | | | | | | - Nitya Batra
- Maulana Azad Medical College, New
Delhi, India
| | | | - Sadia Yaqoob
- Jinnah Medical and Dental College,
Karachi, Pakistan
| | | | | | - Ruchika
- JJM Medical college, Davangere,
India
| | | | - Shehar Bano
- Fatima Jinnah Medical University,
Lahore, Pakistan
| | | | - Sidra Naz
- Harvard Medical School, Boston, MA,
USA
| | - Akash Jaiswal
- All India Institute of Medical
Science, New Delhi, India
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