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How Does Myocarditis After COVID Vaccination Affect Young People?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 1/14/2022
  • Valid for credit through: 1/14/2023
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Target Audience and Goal Statement

This activity is intended for all primary care physicians, pediatricians, cardiologists, nurses, pharmacists, and other members of the healthcare team who care for patients with possible COVID-19 vaccine-associated myocarditis.

The goal of this activity is to analyze characteristics of pediatric patients with myocarditis related to the COVID-19 vaccine.

Upon completion of this activity, participants will:

  • Assess the risk for myocarditis associated with COVID-19
  • Analyze characteristics of pediatric patients with myocarditis related to the COVID-19 vaccine
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape


    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline, Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

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How Does Myocarditis After COVID Vaccination Affect Young People?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 1/14/2022

Valid for credit through: 1/14/2023


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Viral infections are a common cause of myocarditis, and SARS-CoV-2 infection specifically was associated with a 16-fold increase in the risk for myocarditis in a previous study by Boehmer and colleagues. Their research was published in the September 3, 2021 issue of Morbidity and Mortality Weekly Report.[1]

Researchers queried a large database of US hospitals for patient data among adolescent and adult patients between January 2019 and May 2021. To avoid confounding, researchers excluded patients who had received the COVID-19 vaccine.

The overall prevalence of myocarditis increased by 42.3% in comparing data between 2020 and 2019. In this study, 4% of the cohort had a diagnosis of COVID-19 in 2020-2021, and 0.01% had myocarditis; 85.6% of patients with myocarditis had the diagnosis identified during an inpatient encounter.

The prevalence rates of myocarditis among patients with and without COVID-19 were 0.146% and 0.009%, respectively. The adjusted relative risk (ARR) was 15.7 (95% CI: 14.1, 17.2). The ARR for myocarditis associated with COVID-19 exceeded 30 for patients younger than age 16 years and for patients aged 75 years and older.

Study Synopsis and Perspective

Adolescents and adults younger than age 21 years who develop myocarditis after messenger RNA (mRNA) COVID-19 vaccination frequently have abnormal findings on cardiac magnetic resonance imaging (cMRI), but most have a mild clinical course with rapid resolution of symptoms, a new study concluded.

"This study supports what we've been seeing. People identified and treated early and appropriately for the rare complication of COVID-19 vaccine-related myocarditis typically experienced only mild cases and short recovery times," American Heart Association (AHA) President Donald M. Lloyd-Jones, MD, said in a podcast.

"Overwhelmingly, the data continue to indicate the benefits of COVID-19 vaccine far outweigh any very rare risks of adverse events from the vaccine, including myocarditis," Lloyd-Jones added.

The study was published online today in the journal Circulation.[2]

Using data from 26 pediatric medical centers across the United States and Canada, the researchers reviewed the medical records of 139 patients younger than age 21 years with suspected myocarditis within 1 month of receiving a COVID-19 vaccination.

They made the following key observations:

  • Most patients were male (90.6%), White (66.2%), and had a median age of 15.8 years.
  • The majority of suspected myocarditis occurred in 136 (97.8%) patients after mRNA vaccination, with 131 (94.2%) after the Pfizer-BioNTech vaccine; 128 (91.4%) cases occurred after the second dose.
  • Five cases (3.6%) of suspected myocarditis occurred after the Moderna vaccine; one case (0.7%) occurred after the Johnson & Johnson vaccine.
  • Symptoms started a median of 2 (range, 0-22) days after vaccination administration.
  • Chest pain was the most common symptom (99.3%), with fever present in 30.9% of patients and shortness of breath in 27.3%.
  • Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%), or no anti-inflammatory therapies (8.6%).
  • 26 (18.7%) patients were admitted to the intensive care unit (ICU); 2 received inotropic/vasoactive support; none required extracorporeal membrane oxygenation or died.
  • Median time spent in the hospital was 2 days.
  • A total of 111 patients had elevated troponin I (8.12 ng/mL), and 28 had elevated troponin T (0.61 ng/mL).
  • 69.8% had abnormal electrocardiograms and/or arrhythmias (7 with nonsustained ventricular tachycardia).
  • 26 patients (18.7%) had left ventricular ejection fraction (LVEF) < 55% on echocardiogram; LVEF had returned to normal in the 25 who returned for follow-up.
  • 75 (77.3%) of 97 patients who underwent cMRI at a median 5 days from symptom onset had abnormal findings; 74 (76.3%) had late gadolinium enhancement, 54 (55.7%) had myocardial edema, and 49 (50.5%) met Lake Louise criteria for myocarditis.

"These data suggest that most cases of suspected COVID-19 vaccine-related myocarditis in people younger than 21 are mild and resolve quickly," corresponding author Dongngan Truong, MD, division of pediatric cardiology, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, said in a statement.

"We were very happy to see that type of recovery," said Truong; however, we are awaiting further studies to better understand the long-term outcomes of patients who have had COVID-19 vaccination-related myocarditis. We also need to study the risk factors and mechanisms for this rare complication."

Lloyd-Jones said these findings support the AHA's position that COVID-19 vaccines are "safe, highly effective, and fundamental to saving lives, protecting our families and communities against COVID-19 and ending the pandemic."

Study Highlights

  • Patients included in the study presented with possible myocarditis within 30 days of receipt of a COVID-19 vaccine. Researchers drew data from 26 pediatric medical centers in the United States and Canada before July 4, 2021.
  • Patients with normal serum troponin levels or who did not have troponin levels measured were excluded from study analysis, as were patients with an alternative etiology for myocarditis.
  • Investigators analyzed 140 episodes of vaccine-associated myocarditis in 139 patients. One patient presented with myocarditis after both doses of the Pfizer-BioNTech vaccine.
  • 90.6% of patients were male, and 66.2% were White. The median age of patients was 15.8 years.
  • 97.8% of patients had received an mRNA vaccine, with 94.2% having received the Pfizer-BioNTech vaccine; 3.6% having received the Moderna vaccine; 2.1% having received the Johnson & Johnson or an unknown brand vaccine. 91.4% of cases of myocarditis occurred after the second dose of the vaccine.
  • 88.6% of patients had a test for SARS-CoV-2 at the time of presentation with myocarditis. All patients tested negative. 67.6% of patients had no prior COVID-19 with a negative antibody test for SARS-CoV-2.
  • Symptoms occurred at a median of 2 days after vaccine administration. Chest pain was the most common symptom (99.3% of patients). Fever and dyspnea were reported by 30.9% and 27.3% of patients, respectively.
  • 81.3% of patients received nonsteroidal anti-inflammatory drugs. 21.6% received intravenous immunoglobulin, and this same percentage received glucocorticoids.
  • 18.7% of patients required care in an ICU, but only 1.4% required inotropic support. No patient required extracorporeal membrane oxygenation, and no patient died.
  • The median length of hospital stay was 2 days.
  • All patients had elevated levels of troponin I, with a median level of 8.12 ng/mL. Serum C-reactive protein was mildly elevated in the cohort, but brain natriuretic peptide levels were normal.
  • 69.8% of patients had an abnormal electrocardiogram, with ST- or T-wave abnormalities the most common finding.
  • Researchers recorded nonsustained ventricular tachycardia in 5% of patients. 81.3% of patients had normal systolic function on echocardiography. Just 2.8% of patients had moderate or severe systolic dysfunction.
  • All patients with reduced ejection fraction had a normal result on repeat echocardiography.
  • Cardiac MRI was performed in 97 patients at a median of 5 days after diagnosis. 77.3% of these studies were abnormal, with late gadolinium enhancement (98.7% of studies) and myocardial edema (72%) the most common abnormal findings.

Clinical Implications

  • A previous study by Boehmer and colleagues found that the overall ARR for myocarditis associated with COVID-19 was nearly 17, and this value exceeded 30 among adolescents.
  • In the current study by Truong and colleagues of COVID-19 vaccine-associated myocarditis among children and adolescents, nearly all cases of myocarditis followed receipt of an mRNA vaccine. The vast majority of cases were male, and the median age of patients was 15.8 years. Symptoms occurred at a median of 2 days after vaccine administration. Nearly one-fifth (18.7%) of patients required care in an ICU, but only 1.4% required inotropic support. No patients died.
  • Implications for the healthcare team: The healthcare team should counsel patients and caregivers worried about the risk for myocarditis associated with the COVID-19 mRNA vaccines that this complication is very rare and usually resolves quickly. The risk for myocarditis associated with COVID-19 itself appears more significant.


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