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Myocarditis With COVID-19 mRNA Vaccines.
Literature Information
| DOI | 10.1161/CIRCULATIONAHA.121.056135 |
|---|---|
| PMID | 34281357 |
| Journal | Circulation |
| Impact Factor | 38.6 |
| JCR Quartile | Q1 |
| Publication Year | 2021 |
| Times Cited | 507 |
| Keywords | COVID-19, COVID-19 vaccines, SARS-CoV-2, mRNA vaccine, myocarditis |
| Literature Type | Journal Article, Review |
| ISSN | 0009-7322 |
| Pages | 471-484 |
| Issue | 144(6) |
| Authors | Biykem Bozkurt, Ishan Kamat, Peter J Hotez |
TL;DR
This study highlights myocarditis as a rare complication following COVID-19 mRNA vaccination, particularly in young males, with reported rates of approximately 12.6 cases per million doses. Despite the unclear mechanisms behind its occurrence, the findings underscore the favorable benefit-risk assessment for COVID-19 vaccination, recommending it for individuals aged 12 and older due to the overall resolution of symptoms and improved health outcomes.
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COVID-19 · COVID-19 vaccines · SARS-CoV-2 · mRNA vaccine · myocarditis
Abstract
Myocarditis has been recognized as a rare complication of coronavirus disease 2019 (COVID-19) mRNA vaccinations, especially in young adult and adolescent males. According to the US Centers for Disease Control and Prevention, myocarditis/pericarditis rates are ≈12.6 cases per million doses of second-dose mRNA vaccine among individuals 12 to 39 years of age. In reported cases, patients with myocarditis invariably presented with chest pain, usually 2 to 3 days after a second dose of mRNA vaccination, and had elevated cardiac troponin levels. ECG was abnormal with ST elevations in most, and cardiac MRI was suggestive of myocarditis in all tested patients. There was no evidence of acute COVID-19 or other viral infections. In 1 case, a cardiomyopathy gene panel was negative, but autoantibody levels against certain self-antigens and frequency of natural killer cells were increased. Although the mechanisms for development of myocarditis are not clear, molecular mimicry between the spike protein of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and self-antigens, trigger of preexisting dysregulated immune pathways in certain individuals, immune response to mRNA, and activation of immunologic pathways, and dysregulated cytokine expression have been proposed. The reasons for male predominance in myocarditis cases are unknown, but possible explanations relate to sex hormone differences in immune response and myocarditis, and also underdiagnosis of cardiac disease in women. Almost all patients had resolution of symptoms and signs and improvement in diagnostic markers and imaging with or without treatment. Despite rare cases of myocarditis, the benefit-risk assessment for COVID-19 vaccination shows a favorable balance for all age and sex groups; therefore, COVID-19 vaccination is recommended for everyone ≥12 years of age.
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Primary Questions Addressed
- What are the long-term effects of myocarditis following COVID-19 mRNA vaccination?
- How does the incidence of myocarditis compare between different COVID-19 vaccines?
- What are the specific immune responses that lead to myocarditis in certain individuals after mRNA vaccination?
- Are there any demographic factors, aside from age and sex, that influence the risk of developing myocarditis post-vaccination?
- What strategies are being explored to mitigate the risk of myocarditis in populations receiving COVID-19 mRNA vaccines?
Key Findings
Research Background and Objective
Myocarditis has emerged as a rare but significant complication associated with mRNA COVID-19 vaccinations, particularly affecting young adult and adolescent males. The objective of this study is to understand the incidence, clinical presentation, potential mechanisms, and outcomes of myocarditis following mRNA vaccination.
Main Methods/Materials/Experimental Design
The study analyzes reported cases of myocarditis in individuals aged 12 to 39 who received the second dose of mRNA vaccines. Key aspects of the methodology include:
- Data Collection: Cases of myocarditis were reported to health authorities, with emphasis on clinical symptoms, diagnostic findings, and patient demographics.
- Diagnostic Procedures:
- Chest Pain Evaluation: Patients typically presented with chest pain 2-3 days post-vaccination.
- Cardiac Biomarkers: Elevated cardiac troponin levels were measured to assess myocardial injury.
- Electrocardiogram (ECG): ECG findings often showed ST elevations.
- Cardiac MRI: Utilized to confirm myocarditis diagnosis.
- Genetic and Autoantibody Testing: In select cases, cardiomyopathy gene panels and autoantibody levels were analyzed.
The following flowchart illustrates the methodological approach:
Key Results and Findings
- The incidence of myocarditis is approximately 12.6 cases per million doses among individuals aged 12 to 39.
- Common symptoms include chest pain, elevated troponin levels, and abnormal ECGs (predominantly ST elevations).
- Cardiac MRI confirmed myocarditis in all tested cases, with no acute COVID-19 or other viral infections detected.
- Increased autoantibody levels and natural killer cell frequency were noted in some patients, suggesting immune dysregulation.
- Most patients experienced resolution of symptoms and improvement in cardiac markers, with or without treatment.
Main Conclusion/Significance/Innovation
Despite the rare occurrence of myocarditis post-vaccination, the benefits of COVID-19 vaccination outweigh the risks for all age and sex groups. The study highlights the importance of monitoring vaccine-related complications while emphasizing the overall safety and efficacy of COVID-19 vaccinations for individuals aged 12 and older.
Research Limitations and Future Directions
- Limitations: The study is limited by its reliance on reported cases, which may not capture all instances of myocarditis. Additionally, the underlying mechanisms remain poorly understood, necessitating further investigation.
- Future Directions: Further research is needed to explore the mechanisms of myocarditis development, the reasons for male predominance, and long-term outcomes of affected individuals. Enhanced surveillance and reporting systems may improve understanding and management of vaccine-related myocarditis.
| Aspect | Summary |
|---|---|
| Incidence | 12.6 cases/million doses (ages 12-39) |
| Symptoms | Chest pain, elevated troponin, abnormal ECG |
| Diagnostic Findings | Confirmed myocarditis via cardiac MRI |
| Treatment Outcomes | Resolution of symptoms in most cases |
| Benefit-Risk Assessment | Favorable for all age and sex groups |
| Future Research Needs | Mechanisms, male predominance, long-term outcomes |
References
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Literatures Citing This Work
- Coronavirus Disease-2019 and Heart Failure: A Scientific Statement From the Heart Failure Society of America. - Ankeet S Bhatt;Eric D Adler;Nancy M Albert;Anelechi Anyanwu;Nahid Bhadelia;Leslie T Cooper;Ashish Correa;Ersilia M Defilippis;Emer Joyce;Andrew J Sauer;Scott D Solomon;Orly Vardeny;Clyde Yancy;Anuradha Lala - Journal of cardiac failure (2022)
- The bitter news about sweet solutions for the post neonatal age. - Ran D Goldman - CJEM (2021)
- Narrative review on clinical considerations for patients with diabetes and COVID-19: More questions than answers. - Niki Katsiki;Ricardo Gómez-Huelgas;Dimitri P Mikhailidis;Pablo Pérez-Martínez - International journal of clinical practice (2021)
- Exploring the possible link between myocarditis and mRNA COVID-19 vaccines. - Gianfranco Sinagra;Marco Merlo;Aldostefano Porcari - European journal of internal medicine (2021)
- [Acute and chronic cardiac involvement in COVID-19]. - Dietrich Beitzke - Der Radiologe (2021)
- Severe COVID-19 vaccine associated myocarditis: Zebra or unicorn? - Nicholas S Hendren;Spencer Carter;Justin L Grodin - International journal of cardiology (2021)
- COVID-19 vaccination in patients with heart failure: a position paper of the Heart Failure Association of the European Society of Cardiology. - Giuseppe Rosano;Ewa A Jankowska;Robin Ray;Marco Metra;Magdy Abdelhamid;Stamatis Adamopoulos;Stefan D Anker;Antoni Bayes-Genis;Yury Belenkov;Tuvia B Gal;Michael Böhm;Ovidiu Chioncel;Alain Cohen-Solal;Dimitrios Farmakis;Gerasimos Filippatos;Arantxa González;Finn Gustafsson;Loreena Hill;Tiny Jaarsma;Fadi Jouhra;Mitja Lainscak;Ekaterini Lambrinou;Yury Lopatin;Lars H Lund;Davor Milicic;Brenda Moura;Wilfried Mullens;Massimo F Piepoli;Piotr Ponikowski;Amina Rakisheva;Arsen Ristic;Gianluigi Savarese;Petar Seferovic;Michele Senni;Thomas Thum;Carlo G Tocchetti;Sophie Van Linthout;Maurizio Volterrani;Andrew J S Coats - European journal of heart failure (2021)
- Providing children with COVID-19 vaccinations is challenging due to lack of data and wide-ranging parental acceptance. - Jiatong She;Lanqin Liu;Wenjun Liu - Acta paediatrica (Oslo, Norway : 1992) (2022)
- Familial hypercholesterolemia and COVID-19: A menacing but treatable vasculopathic condition. - Alpo Vuorio;Timo E Strandberg;Frederik Raal;Raul D Santos;Petri T Kovanen - Atherosclerosis plus (2021)
- Cardiac involvement in the long-term implications of COVID-19. - Benjamin A Satterfield;Deepak L Bhatt;Bernard J Gersh - Nature reviews. Cardiology (2022)
... (497 more literatures)
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