COVID-19 Vaccine-induced Inflammatory Heart Disease Prevalence Registry

Study Overview
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Brief Summary
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Myocarditis and pericarditis are inflammatory diseases of the myocardium and pericardium, and can be related to different causes, including vaccines. In the past, some people developed inflammatory heart disease after receiving a live or inactive virus vaccine (smallpox vaccine or flu vaccine). Myocarditis was also seen in people with COVID-19. More recently, many countries reported that some people have developed an inflammatory condition of the myocardium or pericardium after receiving a vaccine for COVID-19. After the COVID-19 vaccination campaigns, doctors have noticed more people presenting to the Emergency Department with chest pain and shortness of breath after receiving the vaccine, symptoms that resemble myocarditis or pericarditis. These symptoms may start between 2 to 10 days following vaccination and are frequently noticed after the second dose of the vaccines. While pericarditis seems to affect people of various age groups and gender, myocarditis is more commonly seen in young males. The study will consist of three components. First, the vaccine-induced inflammatory heart disease registry will be established. It will include a retrospective cohort study (chart review). Second, patients with persistent symptoms will be invited to participate in additional research-blood work and a 3-month telephone interview, as some of the patients may display chronic symptoms after developing the condition. Third, there will be a prospective, pragmatic design case-control study. We will collect clinical information and include blood samples for biomarkers twice for cases and once for controls and retrospective patients with persistent symptoms. Follow-up telephone interview will be conducted at the 3 months, 6 months, 12 months and yearly up to 4 years. A record search will also be performed at 6 months, 12 months and yearly for 4 years. The retrospective component of the study will be conducted by identifying patients previously diagnosed with this condition at participating centres.

Detailed Description
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The study will consist of three components. First, the vaccine-induced inflammatory heart disease registry will be established. This will include a retrospective chart review in provinces across Canada. Second, patients with persistent symptoms, identified in the retrospective chart review, will be asked to participate in research bloodwork and phone call follow-ups. Third, there will be a prospective, pragmatic design case-control study. This will be a multi-center study conducted in centers in Canada that treat post-vaccine inflammatory heart disease in both the inpatient and outpatient settings. In Ontario, the major hospitals will include CHEO, London, Toronto, Hamilton, and Kingston. Patients will be invited to participate in the Registry when they present to the Emergency Department, during inpatient admission, or in the Cardiology Outpatient Clinic. Patients will be invited to ask a relative or friend to contact the research site to serve as controls. The retrospective component of the study will be conducted by identifying patients previously diagnosed with this condition at participating centers. At some centers, we will collect clinical information and include blood samples for biomarkers at the baseline/recruitment visit and first follow-up visit for cases and at a research study visit for controls. The follow-up visit is expected to be between 4 and 12 weeks after the initial visit. The research blood samples will be stored and processed at the Ottawa Heart Institute. The UOHI will see the patients for clinical purposes and the research data will be captured at the same time points. These are expected at baseline/initial visit and then a 4-12-weeks follow-up visit. Clinical assessments and bloodwork will be conducted at the two visits. Subsequent follow-up via telephone interview will be conducted after 6 months, 12 months and every year for 4 years, with a script-based questionnaire to ascertain the patient's clinical status and the achievement of clinical endpoints. Patients will be asked to complete a quality-of-life questionnaire. For the case-control study, we will establish a surveillance clinic to assess identified controls. The surveillance clinic will evaluate the clinical aspect of controls and assess whether they are at higher risk of developing post-vaccine myocarditis, myopericarditis, or pericarditis. We will draw clinical bloodwork and request a clinical Holter monitor to assess for subclinical myocarditis and arrhythmias. The Holter monitor duration can be determined by local availability, but the goal will be the shortest duration possible, for example 24-48 hrs. We will draw clinical and research bloodwork only once rather than the two time-points in the cases. We will request a research cardiac MRI for the controls to assess for subclinical myocarditis.

Official Title
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COVID-19 Vaccine-induced Inflammatory Heart Disease Prevalence Registry (COVID-VIHPR)

Conditions
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Myocarditis, Pericarditis

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All patients eligible for vaccination with a COVID-19 vaccine, At least one cardiac symptom of suspected myocarditis/pericarditis within 42 days of receiving a COVID-19 vaccination. The clinical symptoms include chest pain, pressure, or discomfort; dyspnea, shortness of breath/dyspnea/pain with breathing, palpitations, diaphoresis, syncope, or sudden death. OR At least two non-specific symptoms within 42 days of receiving a COVID-19 vaccination. These symptoms include fatigue, abdominal pain, dizziness or syncope, edema, or cough. OR In infants and young children, can also have at least two non-specific symptoms within 42 days of receiving a COVID-19 vaccination. These symptoms include irritability, vomiting, poor feeding, tachypnea, or lethargy. OR No symptoms, but abnormal histopathology or a combination of abnormal cardiac biomarkers with abnormal cardiac imaging (echo or MRI) At least one of the following: a. Elevations in Troponin T, Troponin I, or CK-MB (above threshold of normal) Abnormal MRI (per Brighton Criteria Case Definitions, see Appendix 2 and 3) Any new or worsening cardiac arrhythmias on ECG or telemetry or Holter monitor (per Brighton Criteria Case Definitions, see Appendix 2 and 3) including those that normalize on recovery. Abnormal Echocardiographic findings (per Brighton Criteria Case Definitions, see Appendix 2 and 3) Physical exam finding: Pericardial friction rub or pulsus paradoxus Pericardial fluid or inflammation by imaging (echo, MRI, or CT) or at least one of the following elevated biomarkers of inflammation: ESR, CRP, hs-CRP, or D-Dimer. Enlarged heart on chest radiograph. Histopathologic examination of myocardial tissue (autopsy or endomyocardial biopsy) showed myocardial inflammation Exclusion Criteria: Clear alternative diagnosis or explanation for the symptoms and findings (e.g. infectious myocarditis such as Lyme carditis). Note: Work-up of alternative diagnosis is dependent on clinical presentation e.g. Lyme carditis (e.g. endemic area, season, bullseye rash) or autoimmune heart disease (e.g. arthritis, rash, recurrence). Symptoms after 42 days of vaccination.

Ages Eligible for Study
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Minimum Age: 5 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Prospective (cases)<br>Patients who develop new symptoms of suspected myocarditis/pericarditis within 42 days of receiving a COVID-19 vaccination. The clinical symptoms include chest pain, pressure, or discomfort; dyspnea, shortness of breath, or pain with breathing; palpitations; diaphoresis or sudden death. The symptoms can also be non-specific, including fatigue, abdominal pain, dizziness or syncope, edema, cough or irritability, vomiting, poor feeding, tachypnea or lethargy in young children | |
| Prospective (Control Positive)<br>Family members/relatives who have been vaccinated in a similar timeframe with the participant and had similar reactions | |
| Prospective (Control Negative)<br>Family members/relatives who have been vaccinated in a similar timeframe with the participants but did not experience myocarditis side-effects. If a relative is not available, then a voluntary control who has received the same COVID-19 vaccine in a similar time frame can be recruited. | |
| Retrospective<br>Identified patients, previously diagnosed with the condition, at participating centers | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients with autoimmune disease | To identify how many patients (in each group) have a history of autoimmune disease | 30 days | 
| Composite of MACE | To identify major cardiovascular events - death, ventricular arrhythmia, heart block, heart failure, LV dysfunction (LVEF<55%), cardiac tamponade, re-hospitalization for cardiac reasons | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recurrence of myocarditis/pericarditis | similar symptoms compared to baseline | 3 months, 6 months, 12 months, every year for 4 years | 
| Atrial arrhythmias | irregular atrial heart rhythms | 3 months, 6 months, 12 months, every year for 4 years | 
| Cardiovascular mortality | death from any cardiac cause | 3 months, 6 months, 12 months, every year for 4 years | 
| Quality of life data | EQ-5D-5L questionnaires | 3 months, 6 months, 12 months, every year for 4 years |