Fulminant Myocarditis Following SARS-CoV-2 Infection: JACC Patient Care Pathways

Fulminant Myocarditis with SARS-CoV-2 Infection: A Narrative Review from the Case Studies

One of the severe complications of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is myocarditis. However, the characteristics of fulminant myocarditis with SARS-CoV-2 infection are still unclear. We systematically reviewed the previously reported cases of fulminant myocarditis associated with SARS-CoV-2 infection from January 2020 to December 2022, identifying 108 cases. Of those, 67 were male and 41 female. The average age was 34.8 years; 30 patients (27.8%) were ≤20 years old, whereas 10 (9.3%) were ≥60. Major comorbidities included hypertension, obesity, diabetes mellitus, asthma, heart disease, gynecologic disease, hyperlipidemia, and connective tissue disorders. Regarding left ventricular ejection fraction (LVEF) at admission, 93% of the patients with fulminant myocarditis were classified as having heart failure with reduced ejection fraction (LVEF ≤ 40%). Most of the cases were administered catecholamines (97.8%), and mechanical circulatory support (MCS) was required in 67 cases (62.0%). The type of MCS was extracorporeal membrane oxygenation (n = 56, 83.6%), percutaneous ventricular assist device (Impella®) (n = 19, 28.4%), intra-aortic balloon pumping (n = 12, 12.9%), or right ventricular assist device (n = 2, 3.0%); combination of these devices occurred in 20 cases (29.9%). The average duration of MCS was 7.7 ± 3.8 days. Of the 76 surviving patients whose cardiac function was available for follow-up, 65 (85.5%) recovered normally. The overall mortality rate was 22.4%, and the recovery rate was 77.6% (alive: 83 patients, dead: 24 patients; outcome not described: 1 patient).

Characteristics of Electrocardiogram Findings in Fulminant Myocarditis

Fulminant myocarditis (FM) is an acute and severe form of myocarditis with rapid progression and poor clinical outcomes in the absence of acute or chronic coronary artery disease. Electrocardiogram (ECG) abnormalities can provide preliminary clues for diagnosis; however, there is a lack of systemic descriptions on ECG changes in FM populations. Thus, a retrospective analysis of 150 consecutive FM patients and 300 healthy controls was performed to determine the characteristic ECG findings in FM. All patients included had markedly abnormal ECG findings. Specifically, 83 (55.33%) patients had significantly lower voltage with remarkably decreased QRS amplitudes in all leads compared with healthy controls (p < 0.01), and 77 (51.33%) patients had a variety of arrhythmias with lethality ventricular tachycardia/ventricular fibrillation in 21 (14.00%) patients and third-degree atrioventricular block in 21 (14.00%) patients, whereas sinus tachycardia was only found in 43 (28.67%) patients with the median heart rate (HR; 88.00 bpm, IQR: 76.00-113.50) higher than that of controls (73.00 bpm, IQR: 68.00-80.00) (p = 0.000). Conduction and repolarization abnormalities were common in patients. A longer QTc interval (452.00 ms, IQR: 419.00-489.50) and QRS duration (94.00 ms, IQR: 84.00-119.00) were observed in patients compared to controls (QTc interval = 399.00 ms, IQR: 386.00-414.00; QRS duration = 90.00 ms, IQR: 86.00-98.00) (p < 0.05). Additionally, HR > 86.50 bpm, QTc > 431.50 ms, and RV5 + SV1 < 1.715 mV can be used to predict FM. Thus, marked and severe ECG abnormalities provide preliminary clues for the diagnosis of FM.

Thirty-Day Cardiovascular Readmissions Following Discharge with COVID-19: A US Nationwide Readmission Database Analysis from the Pandemic Year 2020

BACKGROUND

COVID-19 is known to be associated with a myriad of cardiovascular (CV) complications during acute illness, but the rates of readmissions for CV complications after COVID-19 infection are less well established.

METHODS

The U.S Nationwide Readmission Database was utilized to identify COVID-19 admissions from April 1st to November 30th, 2020 using ICD-10-CM administrative claims.

RESULTS

A total of 521,351 admissions for COVID-19 were identified. The all-cause 30-day readmission rate was 11.6% (n=60,262). The incidence of CV readmissions was 5.1% (n=26,725), accounting for 44.3% of all-cause 30-day readmissions. Both CV and non-CV readmissions occurred at a median of 7 days. Patients readmitted with CV causes had a higher comorbidity burden with Charlson comorbidity median score of 6. The most common CV cause of readmission was acute heart failure (HF) (8.5%) followed by acute myocardial infarction (MI) (5.2%). Venous thromboembolism and stroke during 30-day readmission occurred at a rate of 4.6% and 3.6%, respectively. Stress cardiomyopathy and acute myocarditis were less frequent with an incidence of 0.1% and 0.2%, respectively. CV readmissions were associated with higher mortality compared with non-CV readmissions (16.5% vs. 7.5%, p<0.01). Each 30-day CV readmission was associated with greater cost of care than each non-CV readmission ($13,803 vs. $10,310, p=<0.01).

CONCLUSIONS

Among survivors of index COVID-19 admission, 44.7% of all 30-day readmissions were attributed to CV causes. Acute HF remains the most common cause of readmission after COVID-19, followed closely by acute MI. CV causes of readmissions remain a significant source of mortality, morbidity, and resource utilization.

Symptom burden correlates to impairment of diffusion capacity and exercise intolerance in long COVID patients

After acute infection with the SARS-CoV-2 virus, a considerable number of patients remains symptomatic with pathological changes in various organ systems. This study aimed to relate the physical and mental burden of symptoms of long COVID patients to the findings of a somatic evaluation. In patients with persistent long COVID symptoms three months after acute infection we assessed physical and mental health status using the SF-36 questionnaire. The cohort was dichotomised by the results (upper two quartiles vs. lower to quartiles) and compared with regard to transthoracic echocardiography, body plethysmography (including diffusion capacity), capillary blood gas analysis and 6-min walk test (6-MWT). From February 22 to September 13, 2021, 463 patients were prospectively examined, of which 367 completed the SF-36 questionnaire. A positive correlation between initial disease severity (need for hospitalization, intensive care medicine) and resulting symptom burden at follow-up could be demonstrated. Patients with impaired subjective physical and mental status were significantly more likely to be women. There was a significant correlation between symptom severity and reduced exercise tolerance in the 6-MWT (495.6 ± 83.7 m vs 549.7 ± 71.6 m, p < 0.001) and diffusion capacity for carbon monoxide (85.6 ± 14.3% of target vs 94.5 ± 14.4, p < 0.001). In long COVID patients, initial disease severity is correlated with symptom burden after at least 3 months of follow-up. Highly symptomatic long COVID patients show impaired diffusion capacity and 6-MWT despite average or mildly affected mechanical lung parameters. It must be further differentiated whether this corresponds to a transient functional impairment or whether it is a matter of defined organ damage.