What are the symptoms and diagnosis of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the heart lining) related to COVID-19 (coronavirus disease 2019)?

Diagnosing Myocarditis or Pericarditis with COVID-19

If you have chest pain, shortness of breath, palpitations, or syncope during or after COVID-19 infection, you should seek immediate medical attention for evaluation of possible myocarditis or pericarditis. 1

Symptoms to Watch For

Myocarditis Symptoms

• Chest pain (most common cardiac symptom)
• Shortness of breath (dyspnea)
• Palpitations
• Syncope (fainting)
• Fever
• Postexertional fatigue
• Symptoms may persist for 3-12+ months 1, 2

Pericarditis Symptoms

• Sharp chest pain (often worse when lying down, improved by sitting up and leaning forward)
• Shortness of breath
• Fever
• Palpitations 3

Diagnostic Approach

Initial Testing (Triad Testing)

1. ECG - Look for:

   • ST-segment elevation without reciprocal depression
   • Diffuse T-wave inversion
   • Prolongation of QRS complex duration 1, 4

2. Cardiac Troponin (preferably high-sensitivity assay)

   • Elevated levels above the 99th percentile upper reference limit indicate myocardial injury 1
   • Present in 94.8% of COVID-19 myocarditis cases 4

3. Echocardiogram - Look for:

   • Ventricular wall motion abnormalities (often in non-coronary distribution)
   • Abnormal ventricular strain
   • Pericardial effusion or thickening (especially in myopericarditis) 1

Additional Testing

If initial testing suggests myocarditis or pericarditis:

• Cardiac MRI (recommended in hemodynamically stable patients)

  • Most definitive non-invasive test
  • Findings include:
    • Myocardial edema (83.3% of cases)
    • Non-ischemic late gadolinium enhancement (63.9% of cases)
    • Increased native T1 and T2 signals 1, 4

• Inflammatory markers

  • C-reactive protein
  • Erythrocyte sedimentation rate
  • Elevated in 97.8% of COVID-19 myocarditis cases 4

• BNP/NT-proBNP (brain natriuretic peptide)

  • Elevated in heart failure and myocarditis 5

Risk Factors

Individuals at higher risk for COVID-19-related myocarditis:

• Male gender (particularly young males)
• Pre-existing conditions:
  • Hypertension (51.7% of cases)
  • Diabetes mellitus type 2 (46.4% of cases)
  • Pre-existing cardiac conditions (14.6% of cases) 4

When to Seek Emergency Care

Seek immediate medical attention if you experience:

• Severe chest pain
• Significant shortness of breath
• Syncope (fainting)
• Palpitations with lightheadedness
• Symptoms of heart failure (swelling in legs, difficulty breathing when lying flat)

Management

If myocarditis or pericarditis is diagnosed:

• Myocarditis:

  • Hospitalization is recommended for definite myocarditis (mild or moderate)
  • Patients with fulminant myocarditis require advanced heart failure center care
  • Corticosteroids for patients with COVID-19 pneumonia requiring oxygen
  • Heart failure medications as appropriate 1

• Pericarditis:

  • NSAIDs, colchicine, and/or prednisone are reasonable treatment options 1, 3

Important Considerations

• Myocarditis can occur with both COVID-19 infection and (rarely) after COVID-19 vaccination
• COVID-19 vaccination benefits far outweigh risks for all age and sex groups 1, 6
• Cardiac complications increase mortality risk in COVID-19 patients 5
• Routine testing of troponin and BNP levels may help identify at-risk patients 5

Long-term Implications

• Post-acute sequelae of COVID-19 (PASC) may include cardiovascular symptoms persisting 4+ weeks after infection
• Athletes with myocarditis should abstain from exercise for 3-6 months, with gradual return to play after symptoms resolve and testing normalizes 1

Remember that early identification and treatment are critical for improving outcomes in COVID-19-related myocarditis and pericarditis.