Annals for Hospitalists Inpatient Notes - Myocarditis After Vaccination for SARS-CoV-2
Authors: Adam L. Dorfman, Venkatesh L. Murthy
Journal: Annals of Internal Medicine (2021)

Web ExclusivesNovember 2021Annals for Hospitalists Inpatient Notes - Myocarditis After Vaccination for SARS-CoV-2FREEAdam L. Dorfman, MD and Venkatesh L. Murthy, MD, PhDAdam L. Dorfman, MDUniversity of Michigan, Ann Arbor, Michigan (A.L.D., V.L.M.).Search for more papers by this author and Venkatesh L. Murthy, MD, PhDUniversity of Michigan, Ann Arbor, Michigan (A.L.D., V.L.M.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-3871 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A previously healthy 19-year-old man presented with sudden onset of severe, nonradiating chest pain 3 days after receiving a second dose of a messenger RNA (mRNA) SARS-CoV-2 vaccine. He noted 1 day of fatigue and arm soreness after vaccination, which resolved before the onset of chest pain. There was no associated dyspnea, nausea, or vomiting. Work-up included a negative SARS-CoV-2 polymerase chain reaction test result, electrocardiography with diffuse ST-segment elevation, and high-sensitivity cardiac troponin T level of 1029 pg/mL (reference range, 0 to 19 pg/mL). A transthoracic echocardiogram showed left ventricular systolic function within normal range (ejection fraction of 58%), with no regional wall motion abnormalities and no pericardial effusion. He was admitted and received ibuprofen and colchicine. His pain resolved by the following morning. Troponin T levels peaked the day after presentation at 1273 pg/mL; repeated measure of troponin T level 1 month later was within normal range (10 pg/mL). Echocardiography done 4 days after presentation was normal, with an ejection fraction of 67%. Three months after presentation, the patient was asymptomatic. A 7-day ambulatory rhythm monitor showed 25 isolated ventricular ectopic beats. An exercise stress test was normal. A cardiac magnetic resonance image (MRI) showed a small area of subepicardial late gadolinium enhancement but no definite signs of active myocardial inflammation.EpidemiologyMyocarditis and pericarditis after COVID-19 vaccination have occurred at rates higher than expected, particularly among young men and boys. Data from Israel identified a risk ratio of 3.24 (95% CI, 1.55 to 12.44) for myocarditis after mRNA SARS-CoV-2 vaccination across the entire population (1). Rates may be severalfold higher in boys and men aged 12 to 39 years and higher still at the younger end of this age range. Data from the Centers for Disease Control and Prevention showed that among the 12- to 39-year-old age group, compared with the general population, the rate ratio for myocarditis in those who recently received a second dose of an mRNA-based COVID-19 vaccine was 10.8 (CI, 3.2 to 49.0). According to the Centers for Disease Control and Prevention analyses, myocarditis or pericarditis occurred after approximately 1 in 15 500 doses among the highest risk group of boys aged 12 to 17 years (2). Symptoms usually arise 2 to 4 days after vaccination and are far more frequent after the second dose than the first dose of the mRNA vaccine.Presentation and Work-upAs of yet, most data on myocarditis and pericarditis related to COVID-19 vaccination are confined to small case series and administrative data sets. Signs and symptoms seem to be similar to other forms of myocarditis. In a series of 15 pediatric patients (aged 12 to 18 years), symptoms began 3 days (range, 1 to 6 days) after receiving the vaccine. All presented with chest pain, and 67% presented with fever (3). More severe presentations may be accompanied by signs and symptoms of heart failure or arrhythmias.Pericarditis also usually presents with chest pain, which may be pleuritic and positional. Tachycardia may occur in both myocarditis and pericarditis in response to pain or due to impaired cardiac output. A pericardial friction rub may be auscultated. Pericardial inflammation may lead to effusion and overt or early tamponade, which may present with dyspnea, fatigue, edema, or syncope. Importantly, overlap syndromes of myopericarditis also exist.Initial work-up for patients with suspected myocarditis or pericarditis includes a detailed history and physical examination. Troponin as a biomarker of myonecrosis is generally elevated in the setting of acute myocardial inflammation but may normalize in chronic and subacute presentations. Levels of B-type natriuretic peptide may be elevated in either myocarditis or pericarditis but are more useful as indicators of disease severity than for diagnosis. Electrocardiography may demonstrate repolarization abnormalities, including diffuse ST-segment elevation or depression, and may be seen in both myocarditis and pericarditis and in overlap syndromes. Cardiac rhythm monitoring is helpful to evaluate for arrhythmia burden.In patients with risk factors for coronary artery disease, it can be difficult to differentiate myocarditis from myocardial infarction. Consequently, patients with ST-segment elevation require prompt consultation with interventional cardiology. Even without ST-segment elevation, some patients may merit evaluation for coronary artery disease to distinguish infarction from myocarditis. Exercise stress testing may be helpful in guiding resumption of exercise (4).Cardiac imaging plays an important role in the evaluation. Transthoracic echocardiography evaluates left and right ventricular size and systolic function and for the presence of pericardial effusion. Of note, a normal echocardiogram rules out neither myocarditis nor pericarditis. Cardiac MRI can identify areas of myocardial edema and fibrosis in the acute and chronic settings. Prior studies have found that late gadolinium enhancement on cardiac MRI is associated with increased risk for major adverse cardiac events (5). Furthermore, the pattern of fibrosis on cardiac MRI can be helpful for distinguishing postmyocarditis scar from infarction.TreatmentCardiology consultation is reasonable for any patient with confirmed myocarditis or pericarditis as well as for patients with suspected myocarditis or pericarditis and signs or symptoms of heart failure, arrhythmia, biomarker evidence of cardiac myonecrosis, or hemodynamic instability. Management of pericarditis has been evaluated in several randomized trials. First-line medications include colchicine and nonsteroidal anti-inflammatory drugs. Steroids have been associated with recurrence after weaning and a greater burden of adverse effects.Management of myocarditis has been less well studied. However, patients with left ventricular systolic dysfunction should be treated with guideline-directed medical therapies, including an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and a β-adrenergic blocker. Although more advanced systolic dysfunction requiring inotropic drugs, mechanical support, or cardiac transplantation may occur in myocarditis, most cases of SARS-CoV-2 vaccine myocarditis reported thus far have not required these interventions. Outpatient rhythm monitoring may be helpful, depending on symptoms. Exercise testing and biomarkers during the convalescent phase may help guide the resumption of usual activities.PrognosisEvidence suggests that most patients who present with myocarditis or pericarditis related to an mRNA COVID-19 vaccine will fully recover. Published cases have been predominantly mild, with brief hospitalizations and rapid recovery (3). Patients are generally counseled to limit physical activity for several months after diagnosis because it may trigger recurrent inflammation or arrhythmias or exacerbate contractile abnormalities. Outpatient reassessment by a cardiologist is reasonable before the resumption of exercise (4) or weaning of medications. Until additional data about the safety of additional doses of mRNA vaccinations for SARS-CoV-2 after vaccine-associated myocarditis or pericarditis are available, the authors urge caution and careful discussion of risks and benefits with patients before proceeding with additional doses.References1. Barda N, Dagan N, Ben-Shlomo Y, et al. Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting. N Engl J Med. 2021;385:1078-1090. [PMID: 34432976] doi:10.1056/NEJMoa2110475 CrossrefMedlineGoogle Scholar2. Shimabukuro T. COVID-19 vaccine safety update. Advisory Committee on Immunization Practices (ACIP). 23 June 2021. Accessed at www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-06/03-COVID-Shimabukuro-508.pdf on 31 August 2021. Google Scholar3. Dionne A, Sperotto F, Chamberlain S, et al. Association of myocarditis with BNT162b2 messenger RNA COVID-19 vaccine in a case series of children. JAMA Cardiol. 2021. [PMID: 34374740] doi:10.1001/jamacardio.2021.3471 CrossrefMedlineGoogle Scholar4. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104:1694-740. [PMID: 11581152] CrossrefMedlineGoogle Scholar5. Gräni C, Eichhorn C, Bière L, et al. Prognostic value of cardiac magnetic resonance tissue characterization in risk stratifying patients with suspected myocarditis. J Am Coll Cardiol. 2017;70:1964-1976. [PMID: 29025553] doi:10.1016/j.jacc.2017.08.050 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Adam L. Dorfman, MD; Venkatesh L. Murthy, MD, PhDAffiliations: University of Michigan, Ann Arbor, Michigan (A.L.D., V.L.M.).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3871.Corresponding Author: Venkatesh L. Murthy, MD, PhD, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109; e-mail, vlmurthy@med.umich.edu. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists - November 2021 Megan Mack , Matthew Luzum and David H. Wesorick Metrics Cited byCOVID-19-vaccine November 2021Volume 174, Issue 11 Page: HO2-HO3 Keywords Myocarditis Vaccines ePublished: 16 November 2021 Issue Published: November 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. 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