COVID-19-associated pericarditis: Difference between revisions
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Revision as of 08:26, 5 July 2020
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]
Synonyms and keywords: Novel coronavirus, COVID-19, Wuhan Coronavirus, Coronavirus Disease-19, Coronavirus Disease 2019, SARS-CoV-2, COVID-19, COVID-19, 2019-nCoV, 2019 novel coronavirus, Cardiovascular finding in COVID-19, Pericardial injury in COVID-19, Pericarditis, Pericarditis in COVID-19, COVID-19-associated Pericarditis, SARS-CoV2-associated Pericarditis, Myocardial injury in COVID-19, COVID-19 pericarditis
Overview
COVID-19 is caused by the novel coronavirus, also known as SARS-CoV-2. It mainly affects the lungs, causing severe acute respiratory syndrome. It invades through the Angiotensin-converting enzyme 2 (ACE2) receptors present abundantly not only in the lungs but also in the heart, kidneys, intestine, brain, skin thus causing multiorgan dysfunction. Studies have demonstrated that COVID-19 interacts with the cardiovascular system, thereby causing myocardial injury and dysfunction as well as increasing morbidity among patients with underlying cardiovascular conditions. Pericarditis in COVID-19 is a rare complication. Reports on large pericardial effusion and cardiac tamponade are rare in COVID-19
Historical Perspective
- The novel coronavirus, SARS-CoV-2, is identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in late December 2019. SARS-CoV-2 has rapidly spread across China and in other countries, raising major global concerns. This novel coronavirus, SARS-CoV-2, was named the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) for it similarity severe acute respiratory syndrome related coronaviruses such as SARS-CoV, which caused acute respiratory distress syndrome (ARDS) in 2002–2003.[1][2][3][4][5]
- On January 30, 2020,the World Health Organization(WHO) declared the outbreak as a Public Health Emergency of International Concern.[6]
- On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.[7]
Classification
- There is no established system for the classification of the pericarditis seen in COVID-19.
- For more information regarding general classification, see the pericarditis classification.
Pathophysiology
- Viral infections are a common cause of pericarditis. It is hypothesized that viruses cause pericardial inflammation via direct cytotoxic effects or via immune-mediated mechanisms.[8]
- The exact mechanism of COVID-19 induced pericarditis is not yet well known.
- Probable mechanisms of COVID-19-associated pericarditis from the limited cases reported:
- Direct invasion of the virus
- Cytokine storm and systemic hyperinflammatory response: This might be leading to pericarditis and subsequent pericardial effusion in certain patients
Causes
Pericarditis in COVID-19 is caused by:
- Direct invasion by SARS-CoV-2.
- Pro-inflammatory cytokine storm
Differentiating [COVID-19-associated pericarditis] from other Diseases
Pericarditis in COVID-19 must be differentiated from other diseases that cause chest pain, dyspnea such as:
For general information on the differential diagnosis of pericarditis, refer to Differentiating Pericarditis from other Diseases
Epidemiology and Demographics
- Pericarditis is a rare manifestation of COVID-19.
- There is currently no available data on the incidence of pericarditis in COVID-19 patients.
- Very few case reports of pericarditis in COVID-19 patients.[9][10][11][12][13][14][15]
Age
- There is no data on age predilection to pericarditis in COVID-19.
Gender
- There is no data on gender predilection to pericarditis in COVID-19; but among the few cases reported, the number of cases in females is more than males.
Race
- There is no data on racial predilection to pericarditis in COVID-19.
Natural History, Complications and Prognosis
Natural History
- Pericarditis is inflammation of the pericardium.
- There can be an accompanying accumulation of either serous or fibrinous fluid leading to the development of pericardial effusion and cardiac tamponade. *The underlying myocardium may or may not be inflamed as well. If the myocardium is involved in the inflammatory process, it is called myopericarditis, and the CK and troponin levels may be elevated. Subsequent scarring of the pericardium may lead to constrictive pericarditis.
Complications
Common complications include:
Prognosis
There is no sufficient data on prognosis of COVID-19-associated pericarditis.
Diagnosis
Symptoms
- Symptoms of pericarditis in COVID-19 may include the following:
Physical Examination
- Physical examination may be remarkable for:
Laboratory Findings
Inflammatory biomarkers
Non-specific markers of inflammation are commonly elevated in pericarditis.[16] These include:
Elevated inflammatory markers, specifically WBC count and CRP was seen in COVID-19-associated pericarditis cases.[13][9][14][10]
Cardiac biomarkers
In the presence of concomitant myocarditis and pericarditis (myopericarditis), serum biomarkers of myocardial injury, are elevated.[17][18][19] These include:
- Creatinine Kinase (CK)
- Cardiac troponin I or T
- Serum LDH
Elevated cardiac markers was seen in COVID-19-associated pericarditis cases.[10][13][9][14][12]
Electrocardiogram
- Electrocardiogram (ECG) findings see in the reported cases of COVID-!9-associated pericarditis include:
- ST elevation and PR depression are seen;[20][13][12] but these changes are non-specific to COVID-19 pericarditis.
- Non-specific ST changes.[9]
- T wave inversion in the inferior leads (II, III and aVF).[14][21]
For general information on ECG changes in pericarditis, refer to Pericarditis electrocardiogram.
Imaging
Chest X-ray
- Chest X-ray is usually within normal limits in acute pericarditis.
- Chest x-ray demonstrated an enlarged cardiac silhouette in patients with COVID-19 complicated by cardiac tamponade.[9][22]
For general information on CXR findings in pericarditis, refer to Pericarditis x ray
Echocardiography
- Echocardiography is the first-line test in the diagnosis of pericarditis and its complications.[23]
- On imaging by echocardiography in the reported cases of COVID-19-associated pericarditis, findings included:
- Small to moderate pericardial effusion.[10][14][12]
- In the cases complicated by cardiac tamponade,[9][24][12] findings included:
- Large pericardial effusion
- Right ventricular diastolic collapse
- Increased respiratory variation in peak E-wave mitral inflow velocity
- Dilated inferior vena cava
For general information on Echocardiography findings in pericarditis, refer to Pericarditis echocardiography and ultrasound.
CT scan
On CT chest, the reported cases showed pericardial effusion.[13]
Cardiac magnetic resonance
In two of the reported cases, late gadolinium sequences of cardiac magnetic resonance CMR done to rule out myocarditis also showed extensive enhancement of the walls of the heart and the pericardium.[11][10]
Treatment
Medical Therapy
- There is no treatment for [disease name]; the mainstay of therapy is supportive care.
- The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
- [Medical therapy 1] acts by [mechanism of action 1].
- Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
Surgery
- Surgery is the mainstay of therapy for [disease name].
- [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
- [Surgical procedure] can only be performed for patients with [disease stage] [disease name].
Prevention
- There are no primary preventive measures available for COVID-19-associated pericarditis.
- For effective measures for the primary prevention of [COVID-19], refer to COVID-19 primary prevention.
References
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty
|title=(help) - ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
- ↑ Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty
|title=(help) - ↑ "WHO | Novel Coronavirus – China".
- ↑ "Coronavirus (COVID-19) events as they happen".
- ↑ "Coronavirus (COVID-19) events as they happen".
- ↑ Tomkowski, Witold; Swedberg, Karl; Seferovic, Petar; Sabaté Tenas, Manel; Ristić, Arsen D; Pavie, Alain; Mayosi, Bongani; Maisch, Bernhard; Lionis, Christos; Klingel, Karin; Gueret, Pascal; Brucato, Antonio; Bogaert, Jan; Barón-Esquivias, Gonzalo; Badano, Luigi; Imazio, Massimo; Charron, Philippe; Adler, Yehuda; Achenbach, Stephan; Agewall, Stefan; Al-Attar, Nawwar; Angel Ferrer, Juan; Arad, Michael; Asteggiano, Riccardo; Bueno, Héctor; Caforio, Alida L P; Carerj, Scipione; Ceconi, Claudio; Evangelista, Arturo; Flachskampf, Frank; Giannakoulas, George; Gielen, Stephan; Habib, Gilbert; Kolh, Philippe; Lambrinou, Ekaterini; Lancellotti, Patrizio; Lazaros, George; Linhart, Ales; Meurin, Philippe; Nieman, Koen; Piepoli, Massimo F; Price, Susanna; Roos-Hesselink, Jolien; Roubille, François; Ruschitzka, Frank; Sagristà Sauleda, Jaume; Sousa-Uva, Miguel; Uwe Voigt, Jens; Luis Zamorano, Jose; Zamorano, Jose Luis; Aboyans, Victor; Achenbach, Stephan; Agewall, Stefan; Badimon, Lina; Barón-Esquivias, Gonzalo; Baumgartner, Helmut; Bax, Jeroen J; Bueno, Héctor; Carerj, Scipione; Dean, Veronica; Erol, Çetin; Fitzimons, Donna; Gaemperli, Oliver; Kirchhof, Paulus; Kolh, Philippe; Lancellotti, Patrizio; Lip, Gregory YH; Nihoyannopoulos, Petros; Piepoli, Massimo F; Ponikowski, Piotr; Roffi, Marco; Torbicki, Adam; Vaz Carneiro, Antonio; Windecker, Stephan; Shuka, Naltin; Sisakian, Hamayak; Mascherbauer, Julia; Isayev, Elnur; Shumavets, Vadim; Van Camp, Guy; Gatzov, Plamen; Hanzevacki, Jadranka Separovic; Moustra, Hera Heracleous; Linhart, Ales; Møller, Jacob Eifer; Aboleineen, Mohamed Wafaie; Põder, Pentti; Lehtonen, Jukka; Antov, Slobodan; Damy, Thibaud; Schieffer, Bernhard; Dimitriadis, Kyriakos; Kiss, Robert Gabor; Rafnsson, Arnar; Arad, Michael; Novo, Salvatore; Mirrakhimov, Erkin; Stradinš, Peteris; Kavoliuniene, Ausra; Codreanu, Andrei; Dingli, Philip; Vataman, Eleonora; El Hattaoui, Mustapaha; Samstad, Stein Olav; Hoffman, Piotr; Lopes, Luís Rocha; Dimulescu, Doina Ruxandra; Arutyunov, Grigory P; Pavlovic, Milan; Dúbrava, Juraj; Sauleda, Jaume Sagristà; Andersson, Bert; Müller, Hajo; Bouma, Berto J; Abaci, Adnan; Archbold, Andrew; Nesukay, Elena (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Dabbagh, Mohammed F.; Aurora, Lindsey; D’Souza, Penny; Weinmann, Allison J.; Bhargava, Pallavi; Basir, Mir B. (2020). "Cardiac Tamponade Secondary to COVID-19". JACC: Case Reports. doi:10.1016/j.jaccas.2020.04.009. ISSN 2666-0849.
- ↑ 10.0 10.1 10.2 10.3 10.4 Inciardi, Riccardo M.; Lupi, Laura; Zaccone, Gregorio; Italia, Leonardo; Raffo, Michela; Tomasoni, Daniela; Cani, Dario S.; Cerini, Manuel; Farina, Davide; Gavazzi, Emanuele; Maroldi, Roberto; Adamo, Marianna; Ammirati, Enrico; Sinagra, Gianfranco; Lombardi, Carlo M.; Metra, Marco (2020). "Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiology. doi:10.1001/jamacardio.2020.1096. ISSN 2380-6583.
- ↑ 11.0 11.1 Maceira, Alicia M; Lopez-Lereu, Maria P; Higueras Ortega, Laura; García-Gonzalez, Pilar; Broseta Torres, Ricardo; Solsona Caravaca, Javier; Ventura Perez, Bruno; Andres Soler, Jorge; Dominguez Mafe, Eloy; Monmeneu, Jose V; Voges, Inga (2020). "Subacute perimyocarditis in a young patient with COVID-19 infection". European Heart Journal - Case Reports. doi:10.1093/ehjcr/ytaa157. ISSN 2514-2119.
- ↑ 12.0 12.1 12.2 12.3 12.4 Byrne, Jonathan; Sado, Daniel; O’Gallagher, Kevin; Hua, Alina (2020). "Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19". European Heart Journal. 41 (22): 2130–2130. doi:10.1093/eurheartj/ehaa253. ISSN 0195-668X.
- ↑ 13.0 13.1 13.2 13.3 13.4 Cizgici, Ahmet Yasar; Zencirkiran Agus, Hicaz; Yildiz, Mustafa (2020). "COVID-19 myopericarditis: It should be kept in mind in today's conditions". The American Journal of Emergency Medicine. 38 (7): 1547.e5–1547.e6. doi:10.1016/j.ajem.2020.04.080. ISSN 0735-6757.
- ↑ 14.0 14.1 14.2 14.3 14.4 Tung-Chen, Yale (2020). "Acute pericarditis due to COVID-19 infection: An underdiagnosed disease?". Medicina Clínica. 155 (1): 44–45. doi:10.1016/j.medcli.2020.04.007. ISSN 0025-7753.
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".
- ↑ "Diagnosis of acute pericarditis".
- ↑ "Diagnosis of acute pericarditis".
- ↑ Imazio, Massimo; Demichelis, Brunella; Cecchi, Enrico; Belli, Riccardo; Ghisio, Aldo; Bobbio, Marco; Trinchero, Rita (2003). "Cardiac troponin i in acute pericarditis". Journal of the American College of Cardiology. 42 (12): 2144–2148. doi:10.1016/j.jacc.2003.02.001. ISSN 0735-1097.
- ↑ Bonnefoy, E (2000). "Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis". European Heart Journal. 21 (10): 832–836. doi:10.1053/euhj.1999.1907. ISSN 0195-668X.
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".
- ↑ "Diagnosis of acute pericarditis".
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".