COVID-19 and Myocarditis: What Do We Know So Far?

Abstract

COVID-19 has been declared a global pandemic by the World Health Organization and is responsible for hundreds of thousands of deaths worldwide. COVID-19 is caused by SARS-CoV-2, and common clinical symptoms include fever, cough, sore throat, headache, and fatigue. Myocardial injury is relatively common in patients with COVID-19, accounting for 7%-23% of cases, and is associated with a higher rate of morbidity and mortality. There is a discrepancy in the literature about myocarditis as the etiology of myocardial injury in patients with COVID-19; although many anecdotal reports of myocarditis have been noted, there are only a handful of case reports in the literature about myocarditis related to COVID-19. In this review we summarize the most up to date literature around the association between COVID-19 and myocarditis and provide clinicians a practical framework about the clinical manifestations, diagnostic tools, and treatment options currently available. Importantly, this review will heighten suspicion for myocarditis as an etiology of myocardial injury in COVID-19 patients, therefore improving clinical outcomes and encouraging shared clinical decision-making. This will also open the door for further research to build around this review. Emergent treatment options for COVID-19 are in clinical trials and might be of benefit to COVID-19 patients with myocarditis in addition to current guideline-based recommendations.

Figure 1

Mechanisms of pathogenesis and systemic effects of COVID-19 leading to multiorgan damage. ARDS, acute respiratory distress syndrome; CCL2, C-C motif chemokine ligand 2; CCL3, C-C motif chemokine ligand 3; IL, interleukin 1; SARS-COV2, severe acute respiratory syndrome coronavirus 2; TNF, tumour necrosis factor α.

Figure 2

Clinical presentations of patients with biopsy-proven inflammatory heart muscle disease. AV, atrioventricular; CAD, coronary artery disease; CMR, cardiac magnetic resonance; DCM, dilated cardiomyopathy; ECG, electrocardiogram; LV, left ventricular; RV, right ventricular; TnI, troponin I; TnT, troponin T. Modified from Caforio et al. with permission from Oxford University Press.

Figure 3

Summary of clinical approach of published cases of myocarditis associated with COVID-19. BNP, B type natriuretic peptide; CMR, cardiac magnetic resonance; ECG, electrocardiogram; EF, ejection fraction; IL, interleukin; LGE, late gadolinium enhancement.