Original Research

Cardiac Adverse Events Following COVID-19 Vaccination in Patients With Prior Vaccine-Associated Myocarditis

Fed Pract. 2023 January;40(1):6-10 | doi:10.12788/fp.0354

References

2. Engler RJ, Nelson MR, Collins LC Jr, et al. A prospective study of the incidence of myocarditis/pericarditis and new onset cardiac symptoms following smallpox and influenza vaccination. PLoS One. 2015;10(3):e0118283. doi:10.1371/journal.pone.0118283

3. Faix DJ, Gordon DM, Perry LN, et al. Prospective safety surveillance study of ACAM2000 smallpox vaccine in deploying military personnel. Vaccine. 2020;38(46):7323-7330. doi:10.1016/j.vaccine.2020.09.037

4. Montgomery J, Ryan M, Engler R, et al. Myocarditis following immunization with mRNA COVID-19 vaccines in members of the US military. JAMA Cardiol. 2021;6(10):1202-1206. doi:10.1001/jamacardio.2021.2833

5. Witberg G, Barda N, Hoss S, et al. Myocarditis after Covid-19 vaccination in a large health care organization. N Engl J Med. 2021;385(23):2132-2139. doi:10.1056/NEJMoa2110737

6. Oster ME, Shay DK, Su JR, et al. Myocarditis cases reported after mRNA-based COVID-19 vaccination in the US from December 2020 to August 2021. JAMA. 2022;327(4):331-340. doi:10.1001/jama.2021.24110

7. Su JR, McNeil MM, Welsh KJ, et al. Myopericarditis after vaccination, Vaccine Adverse Event Reporting System (VAERS), 1990-2018. Vaccine. 2021;39(5):839-845. doi:10.1016/j.vaccine.2020.12.046

8. Mei R, Raschi E, Forcesi E, Diemberger I, De Ponti F, Poluzzi E. Myocarditis and pericarditis after immunization: gaining insights through the Vaccine Adverse Event Reporting System. Int J Cardiol. 2018;273:183-186. doi:10.1016/j.ijcard.2018.09.054

9. Centers for Disease Control and Prevention (CDC). Update: cardiac-related events during the civilian smallpox vaccination program—United States, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(21):492-496.

10. Gargano JW, Wallace M, Hadler SC, et al. Use of mRNA COVID-19 vaccine after reports of myocarditis among vaccine recipients: update from the Advisory Committee on Immunization Practices—United States, June 2021. MMWR Morb Mortal Wkly Rep. 2021;70(27):977-982. doi:10.15585/mmwr.mm7027e2

11. Sexson Tejtel SK, Munoz FM, Al-Ammouri I, et al. Myocarditis and pericarditis: case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2022;40(10):1499-1511. doi:10.1016/j.vaccine.2021.11.074

12. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. Lancet. 2012;379(9817):738-747. doi:10.1016/S0140-6736(11) 60648-X

13. Heymans S, Cooper LT. Myocarditis after COVID-19 mRNA vaccination: clinical observations and potential mechanisms. Nat Rev Cardiol. 2022;19(2):75-77. doi:10.1038/s41569-021-00662-w

14. Cohen JI, Hohman P, Fulton R, et al. Kinetics of serum cytokines after primary or repeat vaccination with the smallpox vaccine. J Infect Dis. 2010;201(8):1183-1191. doi:10.1086/651453

15. Minocha PK, Better D, Singh RK, Hoque T. Recurrence of acute myocarditis temporally associated with receipt of the mRNA COVID-19 vaccine in an adolescent male. J Pediatr. 2021;238:321-323. doi:10.1016/j.jpeds.2021.06.035

16. Umei TC, Kishino Y, Watanabe K, et al. Recurrence of myopericarditis following mRNA COVID-19 vaccination in a male adolescent. CJC Open. 2022;4(3):350-352. doi:10.1016/j.cjco.2021.12.002

17. Pasha MA, Isaac S, Khan Z. Recurrent myocarditis following COVID-19 infection and the mRNA vaccine. Cureus. 2022;14(7):e26650. doi:10.7759/cureus.26650

18. Block JP, Boehmer TK, Forrest CB, et al. Cardiac complications after SARS-CoV-2 infection and mRNA COVID-19 vaccination—PCORnet, United States, January 2021-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(14):517-523. Published 2022 Apr 8. doi:10.15585/mmwr.mm7114e1

Within 1 month of receipt of any COVID-19 vaccine, 11 individuals had documented symptoms suggesting cardiac involvement, specifically, chest pain, palpitations, or dyspnea. After cardiac evaluation, 4 patients met the criteria for VAMP after COVID-19 vaccination.^10,11 Seven patients either did not meet the criteria for VAMP or had alternative causes for their symptoms.

Two men aged 49 and 50 years with a history of vaccine-associated myocarditis following smallpox vaccination (Dryvax and ACAM2000) developed myocarditis 3 days after their second dose of the Moderna vaccine. One of these patients received a Pfizer-BioNTech booster 10 months later with no recurrence of symptoms. A 55-year-old man with a history of vaccine-associated myocarditis following Dryvax vaccination developed myocarditis 2 days after his Pfizer-BioNTech booster. None of the patients who developed post-COVID-19 VAMP reported residual symptoms from their initial VAMP episode, which occurred 12 to 18 years earlier. All were hospitalized briefly for observation and had complete symptom resolution within 6 weeks.

A 25-year-old man developed pericarditis 4 days after his second Pfizer-BioNTech vaccination. His previous ACAM2000 vaccine-associated myocarditis occurred 3 years earlier, with no residual symptoms. Of note, he had a mild COVID-19 infection 78 days before the onset of his pericarditis. After the onset of his COVID-19 vaccine-associated pericarditis, he continued to experience transient bouts of chest pressure and exertional dyspnea that resolved within 7 months of onset.

The median interval between COVID-19 vaccine doses in those who developed post-COVID-19 VAMP was within the recommended mRNA vaccine dosing intervals of 3 to 4 weeks and was consistent with the median mRNA vaccine dosing intervals among the entire cohort.

Due to the small cohort size and other limitations of this study, the suggested rate of cardiac injury in this review (4 cases in 179 persons, or 2.2%) is an imprecise estimate of risk in a small population (95% CI, 0.1%-4.4%). While this rate may seem higher than expected within the general population after COVID-19 vaccination, it is lower than the estimated lifetime risk of recurrent myocarditis from any cause.^6,12

References

1. Decker MD, Garman PM, Hughes H, et al. Enhanced safety surveillance study of ACAM2000 smallpox vaccine among US military service members. Vaccine. 2021;39(39):5541-5547. doi:10.1016/j.vaccine.2021.08.041

2. Engler RJ, Nelson MR, Collins LC Jr, et al. A prospective study of the incidence of myocarditis/pericarditis and new onset cardiac symptoms following smallpox and influenza vaccination. PLoS One. 2015;10(3):e0118283. doi:10.1371/journal.pone.0118283

3. Faix DJ, Gordon DM, Perry LN, et al. Prospective safety surveillance study of ACAM2000 smallpox vaccine in deploying military personnel. Vaccine. 2020;38(46):7323-7330. doi:10.1016/j.vaccine.2020.09.037

4. Montgomery J, Ryan M, Engler R, et al. Myocarditis following immunization with mRNA COVID-19 vaccines in members of the US military. JAMA Cardiol. 2021;6(10):1202-1206. doi:10.1001/jamacardio.2021.2833

5. Witberg G, Barda N, Hoss S, et al. Myocarditis after Covid-19 vaccination in a large health care organization. N Engl J Med. 2021;385(23):2132-2139. doi:10.1056/NEJMoa2110737

6. Oster ME, Shay DK, Su JR, et al. Myocarditis cases reported after mRNA-based COVID-19 vaccination in the US from December 2020 to August 2021. JAMA. 2022;327(4):331-340. doi:10.1001/jama.2021.24110

7. Su JR, McNeil MM, Welsh KJ, et al. Myopericarditis after vaccination, Vaccine Adverse Event Reporting System (VAERS), 1990-2018. Vaccine. 2021;39(5):839-845. doi:10.1016/j.vaccine.2020.12.046

8. Mei R, Raschi E, Forcesi E, Diemberger I, De Ponti F, Poluzzi E. Myocarditis and pericarditis after immunization: gaining insights through the Vaccine Adverse Event Reporting System. Int J Cardiol. 2018;273:183-186. doi:10.1016/j.ijcard.2018.09.054

9. Centers for Disease Control and Prevention (CDC). Update: cardiac-related events during the civilian smallpox vaccination program—United States, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(21):492-496.

10. Gargano JW, Wallace M, Hadler SC, et al. Use of mRNA COVID-19 vaccine after reports of myocarditis among vaccine recipients: update from the Advisory Committee on Immunization Practices—United States, June 2021. MMWR Morb Mortal Wkly Rep. 2021;70(27):977-982. doi:10.15585/mmwr.mm7027e2

11. Sexson Tejtel SK, Munoz FM, Al-Ammouri I, et al. Myocarditis and pericarditis: case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2022;40(10):1499-1511. doi:10.1016/j.vaccine.2021.11.074

12. Sagar S, Liu PP, Cooper LT Jr. Myocarditis. Lancet. 2012;379(9817):738-747. doi:10.1016/S0140-6736(11) 60648-X

13. Heymans S, Cooper LT. Myocarditis after COVID-19 mRNA vaccination: clinical observations and potential mechanisms. Nat Rev Cardiol. 2022;19(2):75-77. doi:10.1038/s41569-021-00662-w

14. Cohen JI, Hohman P, Fulton R, et al. Kinetics of serum cytokines after primary or repeat vaccination with the smallpox vaccine. J Infect Dis. 2010;201(8):1183-1191. doi:10.1086/651453

15. Minocha PK, Better D, Singh RK, Hoque T. Recurrence of acute myocarditis temporally associated with receipt of the mRNA COVID-19 vaccine in an adolescent male. J Pediatr. 2021;238:321-323. doi:10.1016/j.jpeds.2021.06.035

16. Umei TC, Kishino Y, Watanabe K, et al. Recurrence of myopericarditis following mRNA COVID-19 vaccination in a male adolescent. CJC Open. 2022;4(3):350-352. doi:10.1016/j.cjco.2021.12.002

17. Pasha MA, Isaac S, Khan Z. Recurrent myocarditis following COVID-19 infection and the mRNA vaccine. Cureus. 2022;14(7):e26650. doi:10.7759/cureus.26650

18. Block JP, Boehmer TK, Forrest CB, et al. Cardiac complications after SARS-CoV-2 infection and mRNA COVID-19 vaccination—PCORnet, United States, January 2021-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(14):517-523. Published 2022 Apr 8. doi:10.15585/mmwr.mm7114e1

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Cardiac Adverse Events Following COVID-19 Vaccination in Patients With Prior Vaccine-Associated Myocarditis

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Cardiac Adverse Events Following COVID-19 Vaccination in Patients With Prior Vaccine-Associated Myocarditis

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