COVID-19-associated myocarditis presenting as new-onset heart failure and atrial fibrillation

Abstract

A 58-year-old man presented to the emergency department with recent-onset palpitations and progressive exertional dyspnoea. ECG demonstrated new-onset atrial fibrillation. Transthoracic echocardiogram showed global impairment in left ventricular systolic function with left ventricular ejection fraction of 20%. Cardiac MRI (CMRI) demonstrated generalised severe myocarditis. A SARS-CoV-2 PCR was positive for SARS-CoV-2 RNA. As such, we diagnosed our patient with COVID-19-associated myocarditis based on CMRI appearances and positive SARS-CoV-2 swab. This case highlights that COVID-19-associated myocarditis can present as new atrial fibrillation and heart failure without the classic COVID-19-associated symptoms.

2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults: Myocarditis and Other Myocardial Involvement, Post-Acute Sequelae of SARS-CoV-2 Infection, and Return to Play

“…Although fulminant myocarditis with cardiogenic shock can occur with COVID-19, 53 , 54 , 55 distributive shock resulting from sepsis and/or a hyperinflammatory state can occur as well. In a systematic review of 41 cases of myocarditis associated with COVID-19, cardiogenic shock and distributive shock were noted in 27% and 12% of individuals, respectively.…”

Long-term effect of SARS-CoV-2 infection on cardiovascular outcomes and all-cause mortality

“…Since arrhythmic events have been reported in patients with no previous clinical history [41] , increased arrhythmic complications should be sought in sequelae of SARS-CoV-2 on the heart. Several mechanisms have now been proposed and myocarditis is plausible [42] , [43] . Although there is a desperate need to understand the pathological mechanisms triggered by the virus, the investigation is challenging due to pauci-symptomatic or asymptomatic cases, which leads to underestimating the real incidence of myocarditis [43] .…”

COVID-19 and myocarditis: a review of literature

“…In one report this chest pain was present without fatigue, cough or dyspnea [ 68 ]. Some patients may also present with palpitations alongside their other symptoms [ 67 , 71 ]. After initial presentation, patients may deteriorate to develop signs of heart failure and hemodynamic compromise if treatment is not initiated or is inadequate [ 9 – 11 ].…”

“…After initial presentation, patients may deteriorate to develop signs of heart failure and hemodynamic compromise if treatment is not initiated or is inadequate [ 9 – 11 ]. In severe cases, patients may initially present with new-onset heart failure in the absence of a history of cardiovascular disease [ 71 ]. This is a presentation of fulminant myocarditis, a condition characterized by sudden and severe cardiac inflammation, which may lead to arrythmias, severe heart failure or death [ 72 , 73 ].…”