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CME / ABIM MOC / CE

Are Cardiac Issues Prevalent After COVID-19 Vaccination or Illness?

  • Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 5/27/2022
  • Valid for credit through: 5/27/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

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Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, nurses, pharmacists, physician assistants, and all other members of the healthcare team who advise patients about COVID-19.

The goal of this activity is for learners to be better able to assess the impact of COVID-19 vaccination and SARS-CoV-2 infection on cardiac complications.

Upon completion of this activity, participants will:

  • Analyze the rate of myocarditis/pericarditis associated with messenger RNA COVID-19 vaccines
  • Assess the prevalence and outcomes of myocarditis related to COVID-19
  • Outline implications for the healthcare team


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News Author

  • Sue Hughes

    Journalist
    Medscape Medical News

    Disclosures

    Disclosure: Sue Hughes 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

    Disclosures

    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/Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Nurse Planner

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

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

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

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Are Cardiac Issues Prevalent After COVID-19 Vaccination or Illness?

Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/27/2022

Valid for credit through: 5/27/2023

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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

One of the concerns regarding the application of COVID-19 messenger RNA (mRNA) vaccines has been the risk for cardiac complications such as myocarditis, even though this risk is very small.

The risk for myocarditis associated with COVID-19 is substantially higher than any risk associated with mRNA vaccines, yet acute myocarditis associated with COVID-19 has not been well-characterized.

Study Synopsis and Perspective

New data from 2 different sources on cardiac complications linked to COVID-19 have also shown that such issues are low overall but are higher after infection than after vaccination.

The new information comes from the National Patient-Centered Clinical Research Network of the Centers for Disease Control and Prevention (CDC) and from a separate large international clinical study published in Circulationon April 12.[2]

CDC Data

The CDC study[1] analyzed electronic health record data from 40 US healthcare systems from January 1, 2021 to January 31, 2022 on more than 15 million people aged 5 years or older. Block and colleagues provide context for the CDC study in the April 8, 2022 issue of Morbidity and Mortality Weekly Report.[1] They compared 814,524 patients with COVID-19 infection to the more than 5 million individuals who had received an mRNA COVID-19 vaccine but did not have active infection. The main study outcome was a diagnosis of myocarditis or pericarditis.

Male persons between 12 and 17 years had the highest rates of myocarditis/pericarditis. In this group, there were 50.1 to – 64.9 cases per 100,000 population in the infection group, compared with 2.2 to – 3.3 cases and 22 to .0 – 35.9 cases per 100,000 population in the cohorts with 1 and 2 mRNA vaccines, respectively. A similar pattern was followed in other groups based on age and sex, with the risk for myocarditis/pericarditis being significantly higher in the infection vs . vaccinated cohorts. Children under 12 years had nearly no cases of heart complications after vaccination, and girls and women experienced a lower prevalence (10.9 per 100,000 for females across different age groups and vaccine cohorts) of myocarditis/pericarditis compared with boys.

Even among male persons aged 12 to 17 years, the group with the highest incidence of cardiac complications after receipt of a second mRNA COVID-19 vaccine dose, the risk was 1.8 to 5.6 times higher after SARS-CoV-2 infection than after vaccination, the CDC report noted.

“These findings provide important context for balancing risks and benefits of mRNA COVID-19 vaccination among eligible persons ≥ 5 years," the report states.

International Study

The international study[2] focused on prevalence, clinical characteristics, and outcomes of clinically manifest acute myocarditis in patients with COVID-19. It examined health data on 56,963 patients who were hospitalized with COVID-19 at 23 hospitals across the United States and Europe from February 2020 through April 2021. 

It showed a rate of acute myocarditis of 2.4 per 1000 patients hospitalized with COVID-19. The authors pointed out that these data show much higher frequency and severity of acute myocarditis linked to COVID-19 compared with myocarditis cases linked to the mRNA COVID-19 vaccines.

"A small study previously indicated acute myocarditis is a rare occurrence in people infected with COVID-19. Our analysis of international data offers better insight to the occurrence of acute myocarditis during COVID-19 hospitalization, particularly before the COVID-19 vaccines were widely available," coauthor, Enrico Ammirati, MD, PhD, Niguarda Hospital, Milan, Italy, commented.

"This analysis indicates that, although rare, hospitalized patients with acute myocarditis associated with COVID-19 infection have a much greater need for intensive care unit [(ICU)] admission, in up to 70.5% of the cases, despite the average age of the individuals in the study being much younger than expected at 38 years old," added coauthor Marco Metra, MD, University of Brescia, Italy. 

Overall, 38 patients (70.4%) were admitted to the ICU for a median time of 6 days. Ten patients (18.5%) received temporary mechanical circulatory support for a median time of 5 days. Three patients died (5.5%) during the index hospitalization, all of whom also had pneumonia. At 120 days, estimated mortality was 6.6%. Patients with pneumonia were more likely to develop hemodynamic instability, require mechanical circulatory support, and die compared with patients without pneumonia.

With regard to the prevalence of acute myocarditis after vaccination, they reported that among 2.8 million doses of mRNA COVID-19 vaccine in the armed forces, 23 individuals had evidence of acute myocarditis, suggesting a prevalence of fewer than 1 case of acute myocarditis per 100,000 mRNA COVID-19 vaccine doses.

In addition, they noted that the CDC has also reported 399 reports of myocarditis among 129 million fully vaccinated individuals with the mRNA COVID-19 vaccines.

This study was funded by an Italian Ministry Grant and the Registry of Cardio-Cerebrovascular Pathology, Veneto Region, Venice, Italy.

Study Highlights

  • There were 2.4 cases of definite or probable myocarditis for every 1000 patients admitted for COVID-19.
  • The CDC reported 399 reports of myocarditis among 129 million fully vaccinated individuals with the mRNA COVID-19 vaccines.
  • Male persons between 12 and 17 years had the highest rates of myocarditis/pericarditis. In this group, there were 50.1 to 64.9 cases per 100,000 population in the infection group, compared with 2.2 to 3.3 cases and 22 to 35.9 cases per 100,000 population in the cohorts with 1 and 2 mRNA vaccines, respectively. A similar pattern was followed in other groups according based on age and sex, with the risk for myocarditis/pericarditis being significantly higher in the infection vs. vaccinated cohorts. Children under 12 years had nearly no cases of heart complications after vaccination, and girls and women experienced a lower prevalence (10.9 per 100,000 for females across different age groups and vaccine cohorts) of myocarditis/pericarditis compared with boys.
  • 42.6% of patients had myocarditis with pneumonia, but 57.4% had no pneumonia. Although patients with pneumonia were older and more likely to require supplemental oxygen, the presence of pneumonia was not predictive of cardiogenic shock.
  • The median hospital stay was 13 days; 70.4% of patients with myocarditis required admission to the ICU, and 5.5% of patients died during hospitalization. All fatal cases had pneumonia.
  • At 120 days, the estimated mortality rate was 6.6%. All fatal cases occurred among patients who had pneumonia.

Clinical Implications

  • In a study by Block et al of US medical records focused on the risk for myocarditis/pericarditis associated with COVID-19 or mRNA vaccination, male youths between the ages of 12 and 17 years had the highest rates of myocarditis/pericarditis. Overall, the risk for myocarditis/pericarditis was significantly higher in the infection vs vaccinated cohorts regardless of age and sex. Males individuals had higher rates of myocarditis/pericarditis compared with female persons.
  • The prevalence of myocarditis associated with hospitalization for COVID-19 in the current study by Ammirati and colleagues was 2.4 cases per 1000 admissions. Myocarditis was more common among men, and myocarditis was only diagnosed among individuals who had not received the COVID-19 vaccine; 70% of patients with myocarditis required care in the ICU, and the in-hospital mortality rate was 5.5%.
  • Implications for the healthcare team: The healthcare team can use data from these 2 studies to counsel patients about the risks for COVID-19 vaccination and infection.

 

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