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COVID-19 Vaccine and Myocarditis

      The introduction of the various coronavirus disease-2019 (COVID-19) vaccines has resulted in a significant decline in COVID-19 related morbidity and mortality worldwide, and all the approved COVID-19 vaccines have proven to provide benefits that outweigh the potential risks among different age groups.
      • Haas EJ
      • Angulo FJ
      • McLaughlin JM
      • Anis E
      • Singer SR
      • Khan F
      • Brooks N
      • Smaja M
      • Mircus G
      • Pan K
      • Southern J
      • Swerdlow DL
      • Jodar L
      • Levy Y
      • Alroy-Preis S
      Impact and effectiveness of mRNA BNT162b2 vaccine against SARS-CoV-2 infections and COVID-19 cases, hospitalisations, and deaths following a nationwide vaccination campaign in Israel: an observational study using national surveillance data.
      • Lv G
      • Yuan J
      • Xiong X
      • Li M.
      Mortality rate and characteristics of deaths following COVID-19 vaccination.
      • Lopez Bernal J
      • Andrews N
      • Gower C
      • Robertson C
      • Stowe J
      • Tessier E
      • Simmons R
      • Cottrell S
      • Roberts R
      • O'Doherty M
      • Brown K
      • Cameron C
      • Stockton D
      • McMenamin J
      • Ramsay M
      Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on covid-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study.
      Recent reports have raised concerns for myocarditis related to different types of COVID-19 vaccines. However, there are limited data on the characteristics and outcomes of myocarditis in these patients. In this report, we aim to pool the available data to better understand the characteristics and outcomes of the COVID-19 vaccine-related myocarditis.
      We conducted a search in the PubMed/Medline database from inception till June 27, 2021, using the following terms: ("myocarditis" and "covid-19" and "vaccine") with no language restriction. Inclusion criteria were: (1) case reports, case series, and cohort studies; and (2) individuals who developed myocarditis following a COVID-19 vaccine, regardless of the type or dose of the vaccine. The outcomes of interest were peak cardiac troponin I or T levels, left ventricular ejection fraction (LVEF), duration of symptom, and any reported complication.
      Our search yielded a total of 15 studies. After applying our inclusion criteria, only 8 studies were included with a total of 15 patients.
      • Mansour J
      • Short RG
      • Bhalla S
      • Woodard PK
      • Verma A
      • Robinson X
      • Raptis DA
      Acute myocarditis after a second dose of the mRNA COVID-19 vaccine: a report of two cases.
      • Bautista García J
      • Peña Ortega P
      • Bonilla Fernández JA
      • Cárdenes León A
      • Ramírez Burgos L
      • Caballero Dorta E
      Acute myocarditis after administration of the BNT162b2 vaccine against COVID-19.
      Two of the included studies were case series,
      • Mansour J
      • Short RG
      • Bhalla S
      • Woodard PK
      • Verma A
      • Robinson X
      • Raptis DA
      Acute myocarditis after a second dose of the mRNA COVID-19 vaccine: a report of two cases.
      ,
      • Rosner CM
      • Genovese L
      • Tehrani BN
      • Atkins M
      • Bakhshi H
      • Chaudhri S
      • Damluji AA
      • Lemos JAd
      • Desai SS
      • Emaminia A
      • Flanagan MC
      • Khera A
      • Maghsoudi A
      • Mekonnen G
      • Muthukumar A
      • Saeed IM
      • Sherwood MW
      • Sinha SS
      • O'Connor CM
      • deFilippi CR
      Myocarditis temporally associated with COVID-19 vaccination.
      whereas the rest were case reports.
      • Minocha PK
      • Better D
      • Singh RK
      • Hoque T.
      Recurrence of acute myocarditis temporally associated with receipt of the mRNA COVID-19 vaccine in an adolescent male.
      ,
      • Muthukumar A
      • Narasimhan M
      • Li Q-Z
      • Mahimainathan L
      • Hitto I
      • Fuda F
      • Batra K
      • Jiang X
      • Zhu C
      • Schoggins J
      • Cutrell JB
      • Croft CL
      • Khera A
      • Drazner MH
      • Grodin JL
      • Greenberg BM
      • Mammen PPA
      • Morrison SJ
      • Lemos JAd
      In depth evaluation of a case of presumed myocarditis following the second dose of COVID-19 mRNA vaccine.
      • McLean K
      • Johnson TJ.
      Myopericarditis in a previously healthy adolescent male following COVID-19 vaccination: a case report.
      • D'Angelo T
      • Cattafi A
      • Carerj ML
      • Booz C
      • Ascenti G
      • Cicero G
      • Blandino A
      • Mazziotti S.
      Myocarditis after SARS-CoV-2 vaccination: a vaccine-induced reaction?.
      • Albert E
      • Aurigemma G
      • Saucedo J
      • Gerson DS.
      Myocarditis following COVID-19 vaccination.
      • Bautista García J
      • Peña Ortega P
      • Bonilla Fernández JA
      • Cárdenes León A
      • Ramírez Burgos L
      • Caballero Dorta E
      Acute myocarditis after administration of the BNT162b2 vaccine against COVID-19.
      Fourteen of 15 (93%) of the patients were males. The age range was 17 to 52 years with a mean age of 28 years. Sixty percent of the myocarditis related COVID-19 vaccine cases were associated with the Pfizer-BioNTech vaccine, 33% were associated with the Moderna vaccine, and 7% were associated with the Johnson & Johnson vaccine. All the myocarditis related to the Moderna vaccine (5/5) occurred following the second dose of the vaccine, whereas 6/9 (66.7%) of the myocarditis related to the Pfizer-BioNTech vaccine occurred following the second dose of the vaccine. Peak cardiac troponin I level (ng/mL) was reported in 13/15 patients, and it ranged between 0.37 and 51.37 ng/mL (mean 12.9 ng/mL). Peak troponin T levels were reported in the other 2/15 patients and were 854 ng/L and 1,693 ng/L. Transthoracic echocardiogram in all these patients showed preserved LVEF; exact LVEF value was reported in 13/15 patients with a mean LVEF of 53.5% and a range of 48% to 65%. In the other 2/15 patients, the LVEF was reported as normal with no value. There were no regional wall abnormalities in 14/15 of the patients; 1 patient had subtle apical septal and apical lateral hypokinesis with a LVEF of 52%. All patients recovered within 6 days of their presentation with complications reported (Table 1).
      Table 1Characteristics and outcomes of patients with myocarditis related to COVID-19 vaccine
      AgeSexType of vaccineDosePeak cardiac troponin I (ng/mL)Peak cardiac troponin T (ng/L)LVEF (%)Time to resolution (days)
      125MModerna2nd20.455%3
      221FModerna2nd4.450%1
      317MPfizer-BioNTech1st51.3753%6
      428MJ&JNA17.0850%2
      539MPfizer-BioNTech2nd11.0156%4
      639MModerna2nd1352%3
      724MPfizer-BioNTech1st0.3748%2
      819MPfizer-BioNTech2nd4.4950%3
      920MPfizer-BioNTech2nd0.4852%4
      1023MPfizer-BioNTech2nd750%2
      1152MModerna2nd6.7754%4
      1216MPfizer-BioNTech2nd169361%6
      1330MPfizer-BioNTech2nd12.56"normal"Resolved (duration not reported)
      1424MModerna2nd18.9465%Resolved (duration not reported)
      1539MPfizer-BioNTech1st854"normal"6
      M = male; F = female; LVEF = left ventricular ejection fraction.
      This pooled analysis of the available data shows several important findings. First, myocarditis related to COVID-19 vaccines mostly occurs in young male individuals following the second dose of the vaccine. Second, myocarditis related to COVID vaccines mostly occurs with mRNA vaccines (ie, Pfizer-BioNTech and Moderna COVID-19 vaccines). Third, in all the reported cases of myocarditis related to COVID-19 vaccine, clinical symptoms resolved within 6 days with preservation of the cardiac function. Third, no complications were reported in any of these patients. This analysis shows that myocarditis related to COVID-19 vaccine has an overall fast recovery with no short-term complications.

      Disclosures

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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