Gonzalo M. Bearman, M.D., M.P.H., Chair, Division of Infectious Diseases and Hospital Epidemiologist/Medical Director of VCU Healthcare Infection Prevention Program
Abbate: Myocarditis is inflammation of the heart muscle, and pericarditis is inflammation of the outer lining of the heart. In both cases, the body’s immune system causes inflammation in response to an infection (i.e. viruses) or some other trigger (i.e. drugs). Myocarditis and pericarditis are considered relatively rare conditions, affecting small number of individuals.
Q: What do myocarditis and pericarditis have to do with COVID-19?
Bearman (or Stevens): COVID-19 is an illness caused by the SARS-CoV2 virus that presents mainly with fever and respiratory symptoms. In a small number of patients, an abnormal inflammatory response can ensue within days to weeks after the infection and cause inflammation of the heart muscle (myocarditis) or the sac around the heart (pericarditis).
Q: How common is it for someone with COVID-19 to experience myocarditis or pericarditis?
Turlington: The likelihood of developing myocarditis or pericarditis in patients with COVID-19 is very low. It is estimated that about 150 out of every 100,000 people who develop infection will develop myocarditis or pericarditis. People who develop COVID-19 have an up to 35 times higher risk of developing myocarditis or pericarditis (than people without infection). Myocarditis is to be considered separately from the cases of myocardial injury during critical illness in COVID-19 in which the injury is mediated by sepsis and/or ischemia, and not due to an immune mechanism like in myocarditis.
Q: What are the symptoms and signs of myocarditis or pericarditis secondary to COVID-19?
Shah: Myocarditis and pericarditis commonly present with chest pain and shortness of breath. Nausea, vomiting and abdominal pain can also occur. In rare instances, dizziness, palpitations and loss of consciousness can be manifestations of complications of myocarditis.
Q: Are the symptoms of myocarditis or pericarditis the same for children?
Carter: In general, yes, though small children are less likely to be able or unable to communicate complains of chest pain and shortness of breath. These things show up in children as difficulty feeding, and trouble keeping up with siblings and peers during play. Children are also more likely to have abdominal complaints like vomiting or spitting up, than evidence of chest pain or palpitations.
Q: How serious are myocarditis or pericarditis secondary to COVID-19?
Abbate: Most cases of myocarditis and pericarditis are mild and self-limiting, with symptoms resolving within a few days and without consequences. In some cases, however, treatment is required and, in a small number of cases, the illness can be very serious due to the amount of injury to the heart in myocarditis (fulminant myocarditis) or due to recurrent nature of unresolving chest pain (recurrent pericarditis), or severe inflammatory nature of the response.
Q: How are myocarditis or pericarditis secondary to COVID-19 diagnosed and treated?
Shah: The diagnosis of myocarditis and pericarditis are based on a clinical examination paired with laboratory testing and imaging of the heart structures by echocardiography and/or cardiac magnetic resonance imaging. The treatment depends on the amount of inflammation and injury and generally consists of anti-inflammatory therapies and restriction from exercise. In rare instances, mechanical support to unload the heart and allow for healing is required.
Q: Which patients with COVID-19 myocarditis are treated with immunosuppressive drugs and which drugs?
Danielides: There are no data from randomized clinical trials to guide treatment of COVID-19 related myocarditis, and the data on viral myocarditis is also scant. Consensus-based recommendations are for corticosteroids for the more severe forms of myocarditis as such as those associated with shock, ventricular arrhythmias, or severely reduced cardiac function. Intravenous immunoglobulins are also often administered together with corticosteroids. Targeted immunomodulators, like IL-1 and IL-6 blockers, are used for cases of hyper-inflammatory response such as those with fever, hyperferritinemia, disseminated intravascular coagulation or other manifestation of a hyperactive systemic inflammatory response.
Q: How is treatment different from COVID-19 related myocardial injury?
Turlington: The treatment for COVID-19 related myocardial injury is largely supportive and aimed at restoring the oxygen demand-supply balance on one hand and suppressing systemic inflammation on the other hand.
Q: which treatment for patients with COVID-19 pericarditis?
Abbate: There are no data from randomized clinical trials to guide treatment of COVID-19 related pericarditis. Treatment is based on data available for viral pericarditis. Colchicine and NSAIDs are first line. Corticosteroids are given only if there is another indication or if the patient is failing to response to first line treatments. Targeted immunomodulators, IL-1 blockers, are used for those who are unable to be weaned off corticosteroids or in whom corticosteroids are contraindicated and who have already experienced multiple recurrences despite first line therapies.
Q: How long does one need to restrict exercise after a diagnosis of myocarditis or pericarditis secondary to COVID-19?
Naz: In general, it is recommended to avoid strenuous exercise for 3 or 6 months after a diagnosis of pericarditis or myocarditis, respectively, to allow for proper healing, and reduce risk of recurrences.
Q: Are there long-term consequences of myocarditis or pericarditis?
Hundley: In most cases, with treatment and time the heart muscle and pericardium heal with no long-term consequences. In rare cases however, scarring of the heart or pericardium can remain impairing its function, and require specialized care.
Q: Is there a risk of myocarditis or pericarditis with the SARS-CoV2 mRNA vaccines used to prevent COVID-19?
Danielides: Rare cases of myocarditis reported to the Vaccine Adverse Event Reporting System (VAERS) have occurred after mRNA COVID-19 vaccination (Pfizer-BioNTech or Moderna), especially in male adolescents and young adults, more often after the second dose, usually within several days after vaccination. The Center for Disease Control (CDC) and its partners are actively monitoring reports of myocarditis and pericarditis after COVID-19 vaccination. Active monitoring includes reviewing data and medical records and evaluating the relationship to COVID-19 vaccination. In a very large case-control study of vaccination with Pfizer-BioNTech mRNA vaccination in Israel, the vaccination was association with a very small increased risk of myocarditis. Although the risk related to vaccination may up to 3 times higher than the general population, the risks of developing myocarditis or pericarditis due to COVID-19 itself are up to 35 times higher.
Q: How does the risk for myocarditis or pericarditis associated with SARS-CoV2 mRNA vaccines compare with the risk associated with COVID-19?
Stevens: The risk of myocarditis or pericarditis associated with SARS-CoV2 mRNA vaccines is extremely low and significantly lower than the risk associated with COVID-19. COVID-19 is also associated with a significant risk related to respiratory complications of pneumonia and other complications that are not seen with the vaccine (including “long COVID”).
Q: Is there a particular group of individuals at risk for myocarditis or pericarditis associated with SARS-CoV2 mRNA vaccines?
Carter: Myocarditis and pericarditis, independent of the cause, tend to affect males more than females and younger individuals more than older individuals. The risk of myocarditis or pericarditis associated with SARS-CoV2 mRNA vaccines is very low and the data are limited. The reports available to date show a preference for male adolescents and young adults, more often after the second dose, usually within several days after vaccination.
Q: Do the benefits of vaccination outweigh the potential risks of myocarditis and pericarditis?
Bearman (or Stevens): The CDC continues to recommend that everyone aged 12 years and older get vaccinated for COVID-19. The known risks of COVID-19 illness and its related, possibly severe complications, such as long-term health problems, hospitalization, and even death, far outweigh the potential risks of having a rare adverse reaction to vaccination, including the possible risk of myocarditis or pericarditis.
Q: How common is for someone to experience myocarditis or pericarditis after SARS CoV2 mRNA vaccination?
Turlington: The likelihood of developing myocarditis or pericarditis following SARS-CoV2 mRNA vaccination is extremely low. While there is a small risk of myocarditis or pericarditis with the mRNA COVID-19 vaccine, the risk is much lower than either the risk of mycocarditis from natural COVID-19 infection or the risk of other COVID-19 associated complications such as severe disease and death.
Q: Are the symptoms and signs of myocarditis or pericarditis after SARS-CoV2 mRNA vaccination like those associated with COVID-19?
Shah: For the most part, myocarditis and pericarditis associated with vaccination are mild, and self-limiting. These symptoms are expected to occur within a few days (myocarditis) or few weeks (pericarditis) after the vaccination (generally the second dose but can happen also after the first dose). People with myocarditis or pericarditis after vaccination typically will not have the fever or respiratory symptoms seen with COVID-19
Q: How serious are myocarditis or pericarditis after SARS-CoV2 mRNA vaccination?
Abbate: The great majority of cases of myocarditis and pericarditis after SARS-CoV2 mRNA vaccination are mild and self-limiting, with symptoms resolving within a few days and without consequences. In some very rare cases, however, the illness can be very serious due to the amount of injury to the heart in myocarditis (fulminant myocarditis) or due to recurrent nature of unresolving chest pain (recurrent pericarditis).
Q: How are myocarditis or pericarditis after SARS-CoV2 mRNA vaccination diagnosed and treated?
Naz: The diagnosis and treatment of myocarditis and pericarditis after SARS-CoV2 mRNA vaccination is based on the same strategy as outlined for those associated with COVID-19.
Q: Does a history of myocarditis or pericarditis preclude the use of SARS-CoV2 mRNA vaccination?
Stevens: A history of myocarditis or pericarditis unrelated to COVID-19 or to SARS-CoV2 does not preclude vaccination. If the patient had a prior episode of myocarditis or pericarditis due to COVID-19 or due to SARS-CoV2 mRNA vaccination, it would be advised for the patient to discuss plans for vaccination with their healthcare provider regarding vaccination strategy, timing and choice of vaccine.
Q: Do myocarditis or pericarditis occur with the use of other SARS-CoV2 vaccines?
Bearman (or Stevens): The majority of data available regarding myocarditis and pericarditis associated with the use of SARS-CoV2 vaccination is related to the Pfizer mRNA vaccine. Case reports have linked myocarditis and pericarditis to other vaccines, but the data are very limited.
Q: If a patient has symptoms worrisome for COVID myocarditis or pericarditis, do imaging studies provide additional information?
Hundley: Transthoracic echocardiography or cardiovascular magnetic resonance (also known as cardiac MRI) can be helpful to identify left ventricular wall motion abnormalities that can be present in the setting of myocarditis. Also, patients with pericardial disease can display a fluid collection around the heart (termed: pericardial effusion) that can be seen with both modalities.
Q: If I am referred for a cardiac MRI, is there new or different information that a transthoracic echocardiogram will not provide? Also, what should I expect if I undergo a cardiac MRI?
Hundley: Cardiac MRI scans provide doctors with an ability to understand why heart muscle is behaving abnormally or there is a pericardial effusion. For example if a region of the heart muscle is not contracting normally, the MRI can identify whether that region of tissue has sustained an injury or may exhibit inflammation. Evidence of inflammation of the heart muscle is what doctors are looking for to help establish a diagnosis of myocarditis and evidence of inflammation of the pericardial sack around the heart helps establish a diagnosis of pericarditis. Echocardiography does not necessarily provide this information.
If referred for a cardiac MRI, you will expect to have a procedure that lasts about 45 minutes. The scanner is shaped like a large donut and you rest comfortably on your back and slide up into the round hole of the “donut shaped” magnet. The scanning process does not use ionizing radiation or x-rays. The scanner will make knocking sounds while it makes the images of your heart. Some patients will have an IV for their scan and others will not.
Q: If my child or teen is diagnosed with COVID, what are the recommendations for return to activity?
Carter: Any child or teens with a diagnosis of COVID, with or without symptoms, should have a full 14 days of rest and be without symptoms for a full 14 days before return to play/competition. These children should be seen by their pediatrician before return to play. The pediatricians are encouraged to consult with pediatric cardiology with any questions or concerns. Children and teens who require hospitalization or are diagnosed with MIS-C (multisystem inflammatory syndrome in children) should avoid strenuous activity and be restricted from competitive sports for at least 3 to 6 months. These children should be evaluated and cleared by a pediatric cardiologist before return to play and may require more advanced testing.
