Update on COVID-19 Myocarditis

Abstract

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.

COVID-19 and Acute Myocardial Injury and Infarction: Related Mechanisms and Emerging Challenges

“…Thus, in patients with COVID-19 infection, a garden variety of ACS-NNOCA may be observed ranging from ruptured pre-existing or new atherosclerotic plaques to other ischemic or non-ischemic syndromes, like TTC or acute myocarditis. 57,64,73 -75,77 -79 Importantly, compared with the non-COVID-19 patients, the prevalence of ACS-NNOCA in COVID-19 patients appears to be much higher, reported at ∼33%-55% of patients with COVID-19 presenting with STEMI, 66,67,80 when ACS-NNOCA has been reported to occur in 3.5%-14.5% in non-COVID patients presenting with ACS; 10 the reasons behind this discrepancy have not been elucidated (see discussion on mechanisms below). Notably, the risk of sudden cardiac death (SCD) in patients with ACS-NNOCA remains a major concern; myocardial ischemia, inflammation, and fibrosis are probably at the core of the SCD risk in these patients.…”

Efficacy of the early treatment with tocilizumab-hydroxychloroquine and tocilizumab-remdesivir in severe COVID-19 Patients

“…Several studies indicated that cardiac events and myocarditis were common in hospitalized patients due to COVID-19 infection and this was attributed to the elevation in cardiac enzymes as troponin and lactate dehydrogenase (LDH) [ 51 , 52 ]. On the other hand, elevation in the level of troponin was observed in hospitalized COVID-19 patients taking remdesivir.…”

Fulminant Myocarditis With ST Elevation and Cardiogenic Shock in a SARS-CoV-2 Patient

“…SARS-CoV-2-induced myocarditis is a relatively rare complication that has been reported in multiple case reports [10][11][12][13][14]. Symptoms can range from shortness of breath to cardiogenic shock and fulminant myocarditis, a lifethreatening presentation [15]. In milder cases, patients have responded well to standard therapy of congestive heart failure, including a beta-blocker and angiotensin-converting enzyme inhibitor (ACEI) [11].…”