Determinants of COVID-19 vaccine-induced myocarditis

Design and rationale of the COVID vaccine-associated myocarditis/pericarditis (CAMP) study

BACKGROUND

Minimal data are available on mid- and long-term outcomes following COVID-19 vaccine-associated myocarditis/pericarditis. The COVID Vaccine-Associated Myocarditis/Pericarditis (CAMP) study aims to characterize the mid- and long-term sequelae of myocarditis/pericarditis following administration of any Pfizer-BioNTech COVID-19 vaccine (herein referred to as COMIRNATY®). Herein we describe the rationale and design of CAMP.

METHODS

This ongoing and actively enrolling multicenter observational cohort study across 32 North American pediatric cardiac centers will include at least 200 patients <21 years-old who presented ≤21 days from COMIRNATY® vaccination and meet the Centers for Disease Control and Prevention (CDC) case definition of probable or confirmed myocarditis/pericarditis or isolated pericarditis. The comparison cohort will consist of 100 patients <21 years-old with COVID-19 associated myocarditis/pericarditis, including those who meet the contemporaneous CDC case definition of multisystem inflammatory syndrome (MIS-C). The study will collect detailed hospital and follow-up data for up to 5 years following illness onset. Electrocardiograms, echocardiograms, and cardiac magnetic resonance (CMR) examinations will be interpreted in core laboratories. The primary outcomes are 1) composite of left ventricular ejection fraction <55% by echocardiogram, findings of myocarditis by original or revised Lake Louise criteria on CMR, and/or the presence of high-grade arrhythmias or conduction system disturbances at 6 months after myocarditis/pericarditis onset; 2) complications, such as death, and non-cardiac morbidities; and 3) patient-reported outcomes of global health, functional status, and quality of life. Analyses will include descriptive statistics and regression modeling.

CURRENT STATUS

Still enrolling, with 273 participants currently enrolled as of 10/16/2024 (173 vaccine-associated myocarditis/pericarditis, 100 COVID-19-associated myocarditis/pericarditis) CONCLUSIONS: With long-term follow-up and core laboratories for standardized assessments of cardiac testing, the CAMP study will make important contributions to our understanding of the mid- and long-term cardiac and non-cardiac sequelae of COVID-19 vaccine-associated myocarditis/pericarditis.

Risk stratification for future cardiac arrest after COVID-19 vaccination

Unheralded cardiac arrest among previously healthy young people without antecedent illness, months or years after coronavirus disease 2019 (COVID-19) vaccination, highlights the urgent need for risk stratification. The most likely underlying pathophysiology is subclinical myopericarditis and reentrant ventricular tachycardia or spontaneous ventricular fibrillation that is commonly precipitated after a surge in catecholamines during exercise or the waking hours of terminal sleep. Small patches of inflammation and/or edema can be missed on cardiac imaging and autopsy, and the heart can appear grossly normal. This paper reviews evidence linking COVID-19 vaccines to cardiac arrest where unfortunately the majority of victims have had no antecedent clinical evaluation. We propose a comprehensive strategy for evaluating cardiovascular risk post-vaccination, incorporating detailed patient history, antibody testing, and cardiac diagnostics in the best attempt to detect abnormalities before sudden cardiac death. This approach aims to identify individuals at higher risk of cardiac events after COVID-19 vaccination and guide appropriate clinical management. It is prudent for each primary care physician to have a pre-established plan when addressing this issue in their practice.

The Ambivalence of Post COVID-19 Vaccination Responses in Humans

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has prompted a massive global vaccination campaign, leading to the rapid development and deployment of several vaccines. Various COVID-19 vaccines are under different phases of clinical trials and include the whole virus or its parts like DNA, mRNA, or protein subunits administered directly or through vectors. Beginning in 2020, a few mRNA (Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273) and adenovirus-based (AstraZeneca ChAdOx1-S and the Janssen Ad26.COV2.S) vaccines were recommended by WHO for emergency use before the completion of the phase 3 and 4 trials. These vaccines were mostly administered in two or three doses at a defined frequency between the two doses. While these vaccines, mainly based on viral nucleic acids or protein conferred protection against the progression of SARS-CoV-2 infection into severe COVID-19, and prevented death due to the disease, their use has also been accompanied by a plethora of side effects. Common side effects include localized reactions such as pain at the injection site, as well as systemic reactions like fever, fatigue, and headache. These symptoms are generally mild to moderate and resolve within a few days. However, rare but more serious side effects have been reported, including allergic reactions such as anaphylaxis and, in some cases, myocarditis or pericarditis, particularly in younger males. Ongoing surveillance and research efforts continue to refine the understanding of these adverse effects, providing critical insights into the risk-benefit profile of COVID-19 vaccines. Nonetheless, the overall safety profile supports the continued use of these vaccines in combating the pandemic, with regulatory agencies and health organizations emphasizing the importance of vaccination in preventing COVID-19's severe outcomes. In this review, we describe different types of COVID-19 vaccines and summarize various adverse effects due to autoimmune and inflammatory response(s) manifesting predominantly as cardiac, hematological, neurological, and psychological dysfunctions. The incidence, clinical presentation, risk factors, diagnosis, and management of different adverse effects and possible mechanisms contributing to these effects are discussed. The review highlights the potential ambivalence of human response post-COVID-19 vaccination and necessitates the need to mitigate the adverse side effects.

Ethics of Nudging in the COVID-19 Crisis and the Necessary Return to the Principles of Shared Decision Making: A Critical Review

Nudging, a controversial technique for modifying people's behavior in a predictable way, is claimed to preserve freedom of choice while simultaneously influencing it. Nudging had been largely confined to situations such as promoting healthy eating choices but has been employed in the coronavirus disease 2019 (COVID-19) crisis in a shift towards measures that involve significantly less choice, such as shoves and behavioral prods. Shared decision making (SDM), a method for direct involvement and autonomy, is an alternative approach to communicate risk. Predominantly peer-reviewed scientific publications from standard literature databases like PubMed, PsycInfo, and Psyndex were evaluated in a narrative review. The so-called fear nudges, as well as the dissemination of strongly emotionalizing or moralizing messages can lead to intense psycho-physical stress. The use of these nudges by specialized units during the COVID-19 pandemic generated a societal atmosphere of fear that precipitated a deterioration of the mental and physical health of the population. Major recommendations of the German COVID-19 Snapshot Monitoring (COSMO) study, which are based on elements of nudging and coercive measures, do not comply with ethical principles, basic psychological principles, or evidence-based data. SDM was misused in the COVID-19 crisis, which helped to achieve one-sided goals of governments. The emphasis on utilitarian thinking is criticized and the unethical behavior of decision makers is explained by both using the concept of moral disengagement and the maturity level of coping strategies. There should be a return to an open-ended, democratic, and pluralistic scientific debate without using nudges. It is therefore necessary to return to the origins of SDM.