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Clinical Context

Myocarditis and pericarditis have been associated with mRNA-based COVID-19 vaccines, but just what is the risk for cardiac complications associated with these vaccines? A previous study by Wong and colleagues, published in the June 11, 2022, issue of the Lancet, used a retrospective review of 4 large US healthcare databases to answer this question.^[1]

After more than 27 million doses of BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna), there were a total of 411 myocarditis/pericarditis events recorded in the 7 days after vaccination. Adults between ages 18 and 25 years were at highest risk for myocarditis/pericarditis, and the pooled incidence ratios in this age group were 2.17 and 1.71 events per 100,000 person-days in the mRNA-1273 and BNT162b2 groups, respectively. The difference in event rates in comparing the 2 vaccines was not significant, and expanding the window for diagnosis of myocarditis/pericarditis to 42 days actually lowered the incidence rate of the diagnosis. The risk for myocarditis/pericarditis was higher after the second vs the first vaccine dose.

Healthcare professionals and patients need to weigh the small risk for myocarditis/pericarditis after mRNA-based COVID-19 vaccines with the known risk for cardiac events associated with COVID-19 infection. The current study illuminates the relationship between COVID-19 and cardiac events.

Study Synopsis and Perspective

Among adults hospitalized for COVID-19, acute cardiac events are common, particularly among those with underlying heart disease, and are associated with more severe disease outcomes, a new study suggests.

“We expected to see acute cardiac events occurring among adults hospitalized with COVID-19, but were surprised by how frequently they occurred,” Rebecca C. Woodruff, PhD, MPH, of the US Centers for Disease Control and Prevention in Atlanta, Georgia, told theheart.org | Medscape Cardiology.

Overall, she said, “About 1 in 10 adults experienced an acute cardiac event, including heart attacks and acute heart failure, while hospitalized with COVID-19, and this included people with no preexisting heart disease.”

However, she added, “about a quarter of those with underlying heart disease had an acute cardiac event. These patients tended to experience more severe disease outcomes relative to patients hospitalized with COVID-19 who did not experience an acute cardiac event.”

The findings might be relevant to hospitalizations for other viral diseases, “though we can’t say for sure,” she noted. “This study was modeled off a previous study conducted before the COVID-19 pandemic among adults hospitalized with influenza. About 11.7% of [those] adults experienced an acute cardiac event, which was a similar percentage as what we found among patients hospitalized with COVID-19.”

The study was published online February 6 in the Journal of the American College of Cardiology.^[3]

Underlying Cardiac Disease Key

Dr Woodruff and colleagues analyzed medical records on a probability sample of 8460 adults hospitalized with SARS-CoV-2 infection, identified from 99 US counties in 14 US states (about 10% of the US population) from January to November 2021.

Among participants, 11.4% had an acute cardiac event during their hospitalization. The median age was 69 years, 56.5% were men, 48.7% were non-Hispanic White, 33.6% were non-Hispanic Black, 7.4% were Hispanic, and 7.1% were non-Hispanic Asian or Pacific Islander.

As indicated, the prevalence was higher among those with underlying cardiac disease (23.4%) compared with those without (6.2%).

Acute ischemic heart disease (5.5%) and acute heart failure (5.4%) were the most prevalent events; 0.3% of participants had acute myocarditis or pericarditis.

Risk factors varied, depending on underlying cardiac disease status. Those who experienced 1 or more acute cardiac events had a greater risk for intensive care unit admission (adjusted risk ratio [aRR],1.9) and in-hospital death (aRR, 1.7) vs those who did not.

In multivariable analyses, the risk for experiencing acute heart failure was significantly greater among men (aRR, 1.5) and among those with a history of congestive heart failure (aRR, 13.5), atrial fibrillation (aRR, 1.6), or hypertension (aRR,1.3).

Among patients who experienced 1 or more acute cardiac events, 39.2% required an intensive care unit stay for a median of 5 days. Approximately 22.4% required invasive mechanical ventilation or extracorporeal membrane oxygenation, and 21.1% died while hospitalized.

“Persons at greater risk for experiencing acute cardiac events during COVID-19-associated hospitalizations might benefit from more intensive clinical evaluation and monitoring during hospitalization,” the authors conclude.

The team currently is taking a closer look at acute myocarditis among patients hospitalized with COVID-19, Dr Woodruff said. Preliminary results were presented at the American Heart Association Scientific Sessions 2022 conference, and a paper is forthcoming.^[4]

Contemporary Data Needed

James A. de Lemos, MD, cochair of the American Heart Association’s COVID-19 CVD Registry Steering Committee and professor of medicine at the University of Texas Southwestern Medical Center in Dallas, said that the findings mirror his team’s clinical experience in 2020 and 2021 and echo what was seen in the AHA COVID registry (ie, a 0.3% rate of myocarditis).

“The major caveat is that [the findings] may not be generalizable to contemporary COVID infection, both due to changing viral variants and higher levels of immunity in the population,” he said.

“Rates of COVID hospitalization are markedly lower with the current dominant variants, and we would expect the cardiac risk to be lower as well. I would like to see more contemporary data with current variants, particularly focused on higher risk patients with cardiovascular disease,” Dr de Lemos added.

In a related editorial, George A. Mensa, MD, from the National Heart, Lung and Blood Institute in Bethesda, Maryland, and colleagues suggest that the broader impact of the COVID-19 pandemic on human health remains “incompletely examined.”^[5]

“The impact of COVID-19 on cardiovascular mortality, in particular, appears to have varied widely, with no large increases seen in a number of the most developed countries but marked increases in hypertensive heart disease mortality seen in the United States in 2021,” they conclude. “The potential contribution of COVID-19 to these deaths, either directly or indirectly, remains to be determined.”

No commercial funding or relevant financial relationships were reported.

J Am Coll Cardiol. Published online February 6, 2023.

Clinical Implications

• In a previous study of US databases including more than 27 million doses of BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna) vaccine, the pooled the pooled maximum incidence ratios were 2.17 and 1.71 events per 100,000 person-days in the mRNA-1273 and BNT162b2 groups, respectively. The difference in event rates in comparing the 2 vaccines was not significant. Adults between ages 18 and 25 years were at highest risk for myocarditis/pericarditis, and the risk for myocarditis/pericarditis was higher after the second vs the first vaccine dose.
• The current study found that more than 11% of adult admissions associated with COVID-19 infection had at least 1 cardiovascular event code. The most common cardiovascular events were acute ischemic heart disease (5.5% of admissions) and acute heart failure (5.4% of admissions). Risk factors associated with cardiovascular events associated with COVID-19 admission included older age and Black race; 39.2% of patients with a cardiovascular event required intensive care unit admission for a median of 5 days, and 21.1% of patients with cardiovascular events died during admission.
• Implications for the healthcare team: The healthcare team should educate patients who have an increased risk for cardiovascular events about COVID-19 vaccination and treat acute COVID-19 aggressively among adults with cardiovascular risk factors.

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