Are COVID (Coronavirus Disease 2019) vaccines associated with heart issues, such as myocarditis and pericarditis?

COVID-19 Vaccines and Heart Issues

COVID-19 vaccines are associated with a rare risk of myocarditis and pericarditis, particularly in young males after the second dose, but the overall benefit-to-risk ratio strongly favors vaccination for all age and sex groups. 1

Risk of Myocarditis/Pericarditis After COVID-19 Vaccination

Incidence and Risk Factors

• Myocarditis following COVID-19 mRNA vaccination is rare but documented 1

• Highest risk observed in:

  • Young male individuals aged 12-17 years 1
  • After the second vaccine dose 1
  • Risk difference of 137 per million in males 16-19 years 1
  • Rates in males 12-17 years and 18-24 years after second dose: 377 and 537 cases per million, respectively 1

• Possible differences between mRNA vaccines:

  • Some data suggest higher rates with mRNA-1273 (Moderna) compared to BNT162b2 (Pfizer-BioNTech) 1
  • However, a direct comparison study found no statistically significant difference between the two vaccines 2

Clinical Presentation and Course

• Most cases present within 1 week after vaccination 3
• Typical symptoms include chest pain, dyspnea, palpitations, and syncope 1
• Clinical course is mild in the majority of cases 3, 4
• Diagnostic criteria include:
  • Cardiac symptoms
  • Elevated cardiac troponin
  • Abnormal ECG, echocardiographic, CMR, and/or histopathologic findings 1

Benefit-to-Risk Assessment

Strong Benefit-to-Risk Ratio

• COVID-19 vaccination has a very favorable benefit-to-risk ratio for all age and sex groups 1

• For every 1 million males aged 12-29 years receiving a second dose:

  • 39-47 cases of myocarditis would be expected
  • 560 hospitalizations, 138 ICU admissions, and 6 deaths would be prevented 1

• COVID-19 infection itself is an independent risk factor for cardiovascular disease 5

• COVID-19 infection carries a higher risk of myocarditis than vaccination 5, 6

Evaluation and Management of Suspected Cases

Diagnostic Approach

• For patients with suspicious symptoms after COVID-19 vaccination:
  • Measure serum troponin (preferably high-sensitivity assay)
  • Obtain 12-lead ECG
  • PCR testing for COVID-19 infection
  • Echocardiography for patients with elevated troponin or abnormal ECG 1, 3
  • CMR is recommended in hemodynamically stable patients with suspected myocarditis 1

Treatment Recommendations

• Hospitalization for patients with:

  • Chest pain
  • Elevated troponin
  • Abnormal ECG/echocardiographic/CMR findings
  • Concerning arrhythmias
  • Hemodynamic instability 1

• Treatment options:

  • For mild cases with improving symptoms and normal LVEF: supportive care may be sufficient
  • For ongoing symptoms: NSAIDs, colchicine, and/or corticosteroids
  • For LV dysfunction or hemodynamic instability: IV corticosteroids and circulatory support 1
  • Guideline-directed heart failure therapy for those with reduced ejection fraction 1

• Physical activity restrictions:

  • Avoid strenuous physical activity for 3-6 months 1

Important Considerations for Vaccination

• CDC guidelines recommend:
  • Full vaccination with scheduled booster doses for most people 5
  • Individuals with prior myocarditis/pericarditis unrelated to COVID-19 vaccines can be vaccinated after complete resolution 1
  • For those who developed myocarditis/pericarditis after COVID-19 mRNA vaccination, no further doses of COVID-19 vaccine are recommended 1
  • This decision should be individualized based on risk for severe COVID-19 1

Reporting

• All cases of myocarditis/pericarditis that meet clinical criteria following COVID-19 vaccination should be reported to public health authorities 3

Pitfalls and Caveats

• Do not miss cardiac causes of non-specific post-COVID symptoms (fatigue, dyspnea, chest pain) even in younger adults 5
• Avoid unnecessary delay in diagnosis by maintaining high index of suspicion in young males within a week after vaccination 3, 4
• Remember that the risk of cardiovascular complications from COVID-19 infection exceeds the risk from vaccination 1, 5
• Do not withhold vaccination from the general population due to the rare risk of myocarditis/pericarditis 1, 6