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Cited by 159Viral Infections and Immunology ResearchSARS-CoV-2 and COVID-19 ResearchCOVID-19 Clinical Research Studies

Myocarditis Following COVID-19 Vaccine: Incidence, Presentation, Diagnosis, Pathophysiology, Therapy, and Outcomes Put Into Perspective. A Clinical Consensus Document Supported by the Heart Failure Association of the European Society of Cardiology (ESC) and the ESC Working Group on Myocardial and Pericardial Diseases

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Heidecker, Bettina, Dagan, Noa, Balicer, Ran, Eriksson, Urs, Rosano, Giuseppe, Coats, Andrew, Tschöpe, Carsten, Kelle, Sebastian +10 more·2022·European Journal of Heart Failure
DOI 10.1002/ejhf.2669PMC PMC9538893
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Abstract

Over 10 million doses of COVID-19 vaccines based on RNA technology, viral vectors, recombinant protein, and inactivated virus have been administered worldwide. Although generally very safe, post-vaccine myocarditis can result from adaptive humoral and cellular, cardiac-specific inflammation within days and weeks of vaccination. Rates of vaccine-associated myocarditis vary by age and sex with the highest rates in males between 12 and 39 years. The clinical course is generally mild with rare cases of left ventricular dysfunction, heart failure and arrhythmias. Mild cases are likely underdiagnosed as cardiac magnetic resonance imaging (CMR) is not commonly performed even in suspected cases and not at all in asymptomatic and mildly symptomatic patients. Hospitalization of symptomatic patients with electrocardiographic changes and increased plasma troponin levels is considered necessary in the acute phase to monitor for arrhythmias and potential decline in left ventricular function. In addition to evaluation for symptoms, electrocardiographic changes and elevated troponin levels, CMR is the best non-invasive diagnostic tool with endomyocardial biopsy being restricted to severe cases with heart failure and/or arrhythmias. The management beyond guideline-directed treatment of heart failure and arrhythmias includes non-specific measures to control pain. Anti-inflammatory drugs such as non-steroidal anti-inflammatory drugs, and corticosteroids have been used in more severe cases, with only anecdotal evidence for their effectiveness. In all age groups studied, the overall risks of SARS-CoV-2 infection-related hospitalization and death are hugely greater than the risks from post-vaccine myocarditis. This consensus statement serves as a practical resource for physicians in their clinical practice, to understand, diagnose, and manage affected patients. Furthermore, it is intended to stimulate research in this area.

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  • Myocarditis and pericarditis/myopericarditis from COVID-19 present similarly to other forms of viral myocarditis and pericarditis, with symptoms including fever, cough, chest pain/pressure, dyspnea, palpitations, and syncope.

    “Myocarditis and pericarditis/myopericarditis from COVID-19 present similarly to other forms of viral myocarditis and pericarditis, with symptoms including fever, cough, chest pain/pressure, dyspnea, palpitations, and syncope.”

    From COVID-19, Myocarditis and Pericarditis (2023) · cites this paper as [2]

    The “Diagnosis: Clinical presentation of vaccine-related myocarditis” section (page unavailable) lists chest pain or pressure, shortness of breath, palpitations, and fever, and notes rare syncope in fulminant cases. It describes myocarditis after vaccination, not the presentation of myocarditis or pericarditis from COVID-19 infection; it does not establish the claimed similarity to other viral forms or include cough in its symptom list. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • mRNA vaccines have been found to produce symptoms associated with myocarditis within 3 to 11 days after the second vaccine dose and to produce a mixed infiltrate (macrophages and lymphocytes) in EMB, which is the typical time course of inflammation based on histology from viral and autoimmune myocarditis in patients and animal models.

    “mRNA vaccines have been found to produce symptoms associated with myocarditis within 3 to 11 days after the second vaccine dose and to produce a mixed infiltrate (macrophages and lymphocytes) in EMB (Figure 2), which is the typical time course of inflammation based on histology from viral and autoimmune myocarditis in patients and animal models (eg, lymphocytic, giant cell myocarditis, and CVB3 my”

    From COVID-19, Myocarditis and Pericarditis (2023) · cites this paper as [2]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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  • CD68+ macrophages with fewer T cells are a characteristic finding of immunohistochemistry on EMB from patients with COVID-19 myocarditis/pericarditis.

    “CD68+ macrophages with fewer T cells are a characteristic finding of immunohistochemistry performed on EMB from patients with COVID-19 myocarditis/pericarditis”

    From COVID-19, Myocarditis and Pericarditis (2023) · cites this paper as [2]

    The section ‘Pathology of myocarditis following COVID-19 versus COVID-19 vaccine’ (page unavailable) reports abundant CD68+ macrophages and minimal CD3+ T-cell infiltration in SARS-CoV cardiac tissue, with similar observations in SARS-CoV-2 infection. Figure 6 describes numerous macrophages and low T-cell infiltrates in patients with COVID-19 myocarditis. The paper draws on both EMB and autopsy tissue and does not establish this as a characteristic EMB finding for pericarditis. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Macrophages are the primary infiltrate with fewer T cells in autoimmune models of myocarditis.

    “and macrophages are the primary infiltrate with fewer T cells in autoimmune models of myocarditis (Figure 2). 2,31,127”

    From COVID-19, Myocarditis and Pericarditis (2023) · cites this paper as [2]

    The ‘Pathology of myocarditis following COVID-19 versus COVID-19 vaccine’ section (page unavailable) reports more macrophages than T cells in post-vaccination myocarditis, with similar findings in COVID-19. It does not establish that macrophages are the primary infiltrate in autoimmune models of myocarditis; the claim applies the reported pattern to a different setting. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Signs and symptoms of COVID-19 vaccine-associated myocarditis include shortness of breath, chest pain or pressure, palpitations, malaise, or fatigue, similar to other forms of myocarditis.

    “Signs and symptoms of COVID-19 vaccine-associated myocarditis include shortness of breath, chest pain or pressure, palpitations, malaise, or fatigue, similar to other forms of myocarditis. 2”

    From COVID-19, Myocarditis and Pericarditis (2023) · cites this paper as [2]

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Cited by

Sorted by citations

Authors
Heidecker, B., Dagan, N., Balicer, R., Eriksson, U., Rosano, G., Coats, A., Tschöpe, C., Kelle, S., Poland, G. A., Frustaci, A., Klingel, K., Martin, P., Hare, J. M., Cooper, L. T., Pantazis, A., Imazio, M., Prasad, S., & Lüscher, T. F.
Affiliations
  • Humboldt-Universität zu Berlin (DE)
  • Clalit Health Services (IL)
  • University of Zurich (CH)
  • St George's, University of London (GB)
  • University of Warwick (GB)
  • Deutsches Herzzentrum der Charité (DE)
  • Mayo Clinic (US)
  • Sapienza University of Rome (IT)
  • Universitätsklinikum Tübingen (DE)
  • Cientro Nacional de Investigationes Cardiovasculares , Madrid ,
  • University of Miami (US)
  • Harefield Hospital (GB)
  • University of Udine (IT)
Corresponding author
  • Heidecker, Bettina
  • Lüscher, Thomas F.
ORCID
Venue
European Journal of Heart Failure
Publisher
Oxford University Press (OUP)
Published
2022-10-06
Volume
24
Issue
11
Pages
2000-2018
ISSN
  • 1388-9842 (ISSN-L)
  • 1879-0844
DOI
10.1002/ejhf.2669
PMC
PMC9538893
OpenAlex
W4294723830
Cited by
159
References
12
Citations by year
2026: 23 · 2025: 35 · 2024: 47 · 2023: 47 · 2022: 7
FWCI
23.66
Type
journal article
Language
en
Update notices
correction (2023-02-17)
Open access
Licence
Locations
  • European Journal of Heart Failure (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Warwick Research Archive Portal (University of Warwick) (acceptedVersion)
  • St George's Online Research Archive (St George's University of London) (acceptedVersion)
  • Institutional Research Information System (University of Udine) (submittedVersion, cc-by-nc-nd)
  • Refubium (Universitätsbibliothek der Freien Universität Berlin) (submittedVersion, cc-by-nc-nd)
  • Universitätsbibliothek der FU Berlin Hochschulschriftenstelle u. Dokumentenserver
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Viral Infections and Immunology Research
  • Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
  • Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
Keywords
vaccine-associated myocarditis, COVID-19 vaccines, SARS-CoV-2, cardiac magnetic resonance imaging, troponin, cardiac arrhythmias, heart failure, left ventricular dysfunction, endomyocardial biopsy, anti-inflammatory therapy, corticosteroids, nonsteroidal anti-inflammatory drugs, incidence, risk-benefit assessment
MeSH terms
COVID-19, SARS-CoV-2, COVID-19 Vaccines, Adolescent, Adult, Child, Humans, Young Adult

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