COVID-19-associated pericarditis
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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 caused by the novel coronavirus, also known as SARS-CoV-2 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. Very few cases of COVID-19-associated pericarditis have been reported. 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 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 general classification of pericarditis, click here.
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 are:
- 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 likely caused by:
- Direct invasion by SARS-CoV-2
- Pro-inflammatory cytokine storm
Differentiating COVID-19-associated pericarditis from other diseases
- For further information about the differential diagnosis, click here.
- For further information about the differential diagnosis of COVID-19, click here.
Epidemiology and Demographics
- Pericarditis is a rare manifestation of COVID-19.[9][10][11][12][13][14][15]
- There is currently no available data on the incidence of pericarditis in COVID-19 patients.
- There are few case reports of pericarditis in COVID-19 patients.
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.
- The number of cases in females is more than males among the few cases reported.
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 the 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:
- Fever
- Pericardial friction rub
- Tachycardia, hypotension and distant heart sounds seen in cardiac tamponade
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:
- Creatine 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-19-associated pericarditis include:
- ST elevation and PR depression are seen;[20][13][12] but these changes are not specific to COVID-19 pericarditis.
- Non-specific ST changes.[9]
- T wave inversion in the inferior leads (II, III and aVF).[14][21]
- For ECG changes in pericarditis in general, click here.
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 Chest X-ray findings in pericarditis, click here.
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, findings included: [9][24][12]
- Large pericardial effusion
- Right ventricular diastolic collapse
- Increased respiratory variation in peak E-wave mitral inflow velocity
- Dilated inferior vena cava
For echocardiography findings in pericarditis in general, click here.
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]
Pericardial fluid analysis
- In the reported cases of cardiac tamponade in COVID-19 patients, pericardial fluid analysis from emergency pericardiocentesis showed:[9][25]
- Other work-up included:
- Fluid cytology for malignant cells - negative
- Gram stain, Acid-fast stain - negative
- Bacterial, mycobacterial and fungal cultures - negative
- Serum auto-immune work-up - negative
- Since there are no established laboratory parameters to help distinguish COVID-19-related pericardial effusion from other etiologies, complete biochemical, bacteriological and cytological analysis of pericardial fluid is suggested to rule out other etiologies of pericardial effusion.
Treatment
Medical Therapy
- NSAIDs and high-dose aspirin and are the mainstay of therapy for acute pericarditis.[8]
- Colchicine is recommended as first-line therapy for acute pericarditis as an adjunctive to NSAIDs/Aspririn
- Corticosteroids are reserved for cases with a contraindication or failure of first-line therapies.
- With early anecdotal reports linking NSAIDs and corticosteroids with a worsening clinical condition in patients with COVID-19, there have been recommendations against the use of these agents.[26][27] However, according to the recommendations from the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), NSAIDs can be used when clinically indicated in COVID-19 patients.[28]
- There is no literature and existing data to provide definite evidence for or against the use of high- or low-dose aspirin when clinically indicated in patients with COVID-19.
- In one of the reported cases of COVID-19-associated pericarditis and cardiac tamponade, colchicine was well tolerated as monotherapy.[29]
- In another case of COVID-19 and cardiac tamponade, the combination of corticosteroids and colchicine was well tolerated and successful.[9]
- Response to treatment can be monitored with serial transthoracic echocardiogram (TTE).
Surgery
- In all the reported cases of COVID-19 with large effusions and cardiac tamponade, pericardiocentesis showed improvement in symptoms.
- Response to treatment can be monitored with serial transthoracic echocardiogram (TTE).
Primary Prevention
- There are no established measures for the primary prevention of COVID-19-associated pericarditis.
- For primary preventive measures of [COVID-19], click here.
Secondary Prevention
- There are no established measures for the secondary prevention of COVID-19-associated pericarditis.
- For secondary preventive measures of [COVID-19], click here.
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".
- ↑ 8.0 8.1 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 9.6 9.7 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".
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".
- ↑ Russell, Beth; Moss, Charlotte; Rigg, Anne; Van Hemelrijck, Mieke (2020). "COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting?". ecancermedicalscience. 14. doi:10.3332/ecancer.2020.1023. ISSN 1754-6605.
- ↑ Bancos, Simona; Bernard, Matthew P.; Topham, David J.; Phipps, Richard P. (2009). "Ibuprofen and other widely used non-steroidal anti-inflammatory drugs inhibit antibody production in human cells". Cellular Immunology. 258 (1): 18–28. doi:10.1016/j.cellimm.2009.03.007. ISSN 0008-8749.
- ↑ "FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19 | FDA".
- ↑ "View of Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge".