Acute viral myocarditis presenting as sudden cardiac arrest and refractory ventricular tachycardia

COVID-19 Vaccination and Cardiac Arrhythmias: A Review

PURPOSE OF REVIEW

In this review, we aim to delve into the existing literature, seeking to uncover the mechanisms, investigate the electrocardiographic changes, and examine the treatment methods of various cardiac arrhythmias that occur after administration of the COVID-19 vaccine.

RECENT FINDINGS

A global survey has exposed an incidence of arrhythmia in 18.27% of hospitalized COVID-19 patients. Furthermore, any type of COVID-19 vaccine - be it mRNA, adenovirus vector, whole inactivated, or protein subunit - appears to instigate cardiac arrhythmias. Among the cardiac adverse events reported post-COVID-19 vaccination, myocarditis emerges as the most common and is thought to be a potential cause of bradyarrhythmia. When a patient post-COVID-19 vaccination presents a suspicion of cardiac involvement, clinicians should perform a comprehensive history and physical examination, measure electrolyte levels, conduct ECG, and carry out necessary imaging studies. In our extensive literature search, we uncovered various potential mechanisms that might lead to cardiac conduction abnormalities and autonomic dysfunction in patients who have received the COVID-19 vaccine. These mechanisms encompass direct viral invasion through molecular mimicry/spike (S) protein production, an escalated inflammatory response, hypoxia, myocardial cell death, and the eventual scar/fibrosis. They correspond to a range of conditions including atrial tachyarrhythmias, bradyarrhythmia, ventricular arrhythmias, sudden cardiac death, and the frequently occurring myocarditis. For treating these COVID-19 vaccination-induced arrhythmias, we should incorporate general treatment strategies, similar to those applied to arrhythmias from other causes.

Increased emergency cardiovascular events among under-40 population in Israel during vaccine rollout and third COVID-19 wave

Cardiovascular adverse conditions are caused by coronavirus disease 2019 (COVID-19) infections and reported as side-effects of the COVID-19 vaccines. Enriching current vaccine safety surveillance systems with additional data sources may improve the understanding of COVID-19 vaccine safety. Using a unique dataset from Israel National Emergency Medical Services (EMS) from 2019 to 2021, the study aims to evaluate the association between the volume of cardiac arrest and acute coronary syndrome EMS calls in the 16-39-year-old population with potential factors including COVID-19 infection and vaccination rates. An increase of over 25% was detected in both call types during January-May 2021, compared with the years 2019-2020. Using Negative Binomial regression models, the weekly emergency call counts were significantly associated with the rates of 1st and 2nd vaccine doses administered to this age group but were not with COVID-19 infection rates. While not establishing causal relationships, the findings raise concerns regarding vaccine-induced undetected severe cardiovascular side-effects and underscore the already established causal relationship between vaccines and myocarditis, a frequent cause of unexpected cardiac arrest in young individuals. Surveillance of potential vaccine side-effects and COVID-19 outcomes should incorporate EMS and other health data to identify public health trends (e.g., increased in EMS calls), and promptly investigate potential underlying causes.

ECMO in tropical diseases

Diseases prevalent in tropics present with varied manifestations compared to diseases that occur commonly in the temperate climate (the West). Tropical diseases contribute to significant mortality and morbidity. If diagnosed at the right time, tropical diseases have good prognosis too. Utilizing the useful function of supporting the cardio-pulmonary status in these critically ill disease states would be very useful to save thousands of lives each year. As these diseases are not frequent in the West, apart from reporting the experiences in the form of an anecdotal case report, much guidance is not available in their management.

Immune reconstitution inflammatory syndrome and human immunodeficiency virus-associated myocarditis

Myocarditis is a well-recognized cardiac manifestation of human immunodeficiency virus (HIV) infection, and alterations in the immune system likely play an important role in the pathogenesis of heart muscle disease in HIV-infected patients. Highly active antiretroviral therapy (HAART) has greatly improved survival in HIV patients but not without uncovering new and unique manifestations of disease. Immune reconstitution inflammatory syndrome is a collection of inflammatory disorders in which a pathologic inflammatory response and clinical deterioration occur during recovery of the immune system after HAART. To our knowledge, a correlation between immune reconstitution inflammatory syndrome and HIV-associated myocarditis has not been described previously. We report a case of acute myocarditis presenting with refractory ventricular arrhythmias in a patient with AIDS who experienced rapid immune recovery with the initiation of HAART. The case underscores the importance of recognizing this potential complication of AIDS treatment and calls for renewed vigilance concerning cardiac manifestations of HIV, especially during the immune reconstitution phase.

Idiopathic cardiac electrical storm

Cardiac electrical storm has been described as three or more distinct episodes of ventricular fibrillation or hemodynamically destabilizing ventricular tachycardia in a 24-h period, typically requiring treatment with electrical cardioversion or defibrillation. We report the case of a 45-year-old man who presented to the Emergency Department with idiopathic cardiac electrical storm, ultimately requiring defibrillation over 30 times in the Emergency Department and infusion of multiple antidysrhythmic agents for dysrhythmia control. Treatment of cardiac electrical storm entails immediate resuscitative therapy during the hemodynamically destabilizing episode (including cardioversion/defibrillation and the timely administration of antidysrhythmic agents), concurrent identification and correction of any factors that are potentially contributing to the acute dysrhythmia (i.e., electrolyte disturbances, myocardial ischemia), and ultimately, institution of long-term preventive therapy (such as an implantable cardioverter defibrillator) to quell recurrence. Amiodarone and beta-adrenergic blockers seem to be the agents of greatest clinical benefit to patients with cardiac electrical storm. Despite its potentially devastating nature, the majority of patients with cardiac electrical storm may have favorable clinical outcomes if the dysrhythmias are treated swiftly and aggressively.