Summary of the recently published ACC consensus 2022 about the cardiovascular sequalae of Covid-19 infection
Lecture link: https://youtu.be/7JBG2v8YLpA
6. D.D of myocardial injury in SARS-CoV-2
(means↑ cTn level > 99th % URL)
SARS-CoV-2
Myocarditis
Type 1 or 2
MI
Takotsubo
Pulmonary
embolism
Chronic
condition
(HF)
MIS-A
Cytokine
storm
↑ cTn
worse prognosis regardless the cause
7. Important terminology
• Myocardial injury: means↑ cTn level > 99th % URL (Very wide D.D)
• Myocardial involvement: means abnormal myocardium as evident by (ECG,
echo, CMR and/or histopathology) (+/- )symptoms (+/-) ↑( cTn)
• Myocarditis: Cardiac symptoms + abnormal myocardium (ECG, echo, CMR
and/or histopathology)+myocardial injury ↑(cTn) after exclusion of
coronary artery disease
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
8. Myocarditis
Ideally, after exclusion of CAD in men >50 years and women > 55 years
• Possible myocarditis: Cardiac symptoms + elevated cTn + abnormal (ECG or
ECHO) but no evidence of acute myocarditis by biopsy or CMR or neither
were performed
• Definite myocarditis: Features of possible myocarditis + CMR and/or biopsy
during acute course demonstrates active myocarditis
• Probable myocarditis: Features of possible myocarditis+ FU CMR or biopsy
within 6 months of infection demonstrates old abnormalities (LGE)
9. Myocarditis
• Incidence: Variable in different reports (Definition?, timing ,modality)
• Risk factors: Male (68%), DM, HTN, obesity, old age, Comorbidities
• 3 Phases: 1st > Innate immune (1-7 days), 2nd> acquired immune
response /cytokines (7-30 days), 3rd> remodeling phase (>30 days)
• Mechanism: Different theories (Direct viral invasion “mRNA detected
extracellular in 25%”?- maladaptive immune response?-
microangiopathy?-molecular mimicry?-Hypoxia?)
11. For example: CTPA for pulmonary embolism
Coronary angiography for ACS
Medical therapy:
Myocarditis: Steroids if serve lung injury or MIS-A
Or hemodynamic compromise with no sepsis
Pericarditis: NSAID and colchicine
Endomyocardial biopsy: Fulminant myocarditis
or heart block
or Ventricular arrhythmia:
For example:
ECG: Diffuse T wave inversion,
ST elevation without reciprocation, wide QRS
Echo: Non-territorial RWMA or abnormal strain
Consider 3-6 months FU (ECG, echo, holter, CMR)
especially severe cases or persistent symptoms
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
13. mRNA vaccines
mechanism : (molecular mimicry?, immune dysregulation?)
Very low
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
14. For example: CTPA for pulmonary embolism
Coronary angiography for ACS
For example:
ECG: Diffuse T wave inversion,
ST elevation without reciprocation, wide QRS
Echo: Non-territorial RWMA or abnormal strain
Avoidance further vaccine doses is recommended
after discussion with the patient
Same workup
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
17. (PASC)
“Constellation of unexplained new, recurrent or persistent health problems”
≥ 4 weeks after SARS-CoV-2 (CDC definition)
≥ 12 weeks after SARS-CoV-2 (NICE and WHO definition)
≥ 4 weeks after mild infection, ≥ 12 weeks after severe infection (ACC consensus)
18. Other syndromes with overlapping symptoms
(Not fully explaining the wide spectrum of PASC)
• POTS (Postural orthostatic tachycardia syndrome)
Def: Heart rate >30/min. above the supine rate after 5-10 min. of quiet standing
(frequently> 120/min.) in the absence of orthostatic hypotension
• Chronic fatigue syndrome:
Def: Triad of: 1) Impairment of function at home or at work, lasting > 6 months
with profound fatigue of definite onset not ↓ by rest + 2) post-exertional
malaise + 3) unrefreshing sleep
Both have been described to possibly occur post-many infections eg. CMV, EPV
26. Why?
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
Data from Initial small sample size reports were worrisome
27. Why?
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
Data from larger registries are reassuring
28. CMR limitations
1- “Modified Lake Louise criteria” > not validated as a screening tool for
asymptomatic patients, so clinical relevance of isolated abnormal CMR finding is
still unknown
2- Paucity of athlete-specific normative data, For example (LGE in masters-level)
3- Mapping requires a high level of expertise (Possible bias or errors)
4-Absence of an appropriate control group limits the interpretation of clinical
significance CMR findings
5-High cost, limited availability
6-Importantly, no confirmed cases of cardiac death in the registries of athletes
with COVID-19 !
31. After proven myocarditis
• After abstinence (3-6 months) RTP would be based on:
1) Absence of cardiopulmonary symptoms
2) Resolution of laboratory evidence of myocardial injury
3) Normalization of LV systolic function
4) Absence of spontaneous/inducible cardiac arrhythmias on ECG
monitoring and exercise stress testing
32. The dilemma of isolated LGE in CMR screening
• Resolving myocarditis should be considered if :
1) High clinical suspicion of myocarditis
2) Abnormal findings on other testing (ECG, cTn)
3) Pattern of LGE suggestive of myocarditis
4) Mildly reduced LV systolic function
• if it is determined that acute myocarditis is less likely consider:
> maximal-effort exercise testing, stress echocardiography for reduced
LV systolic function to assess for appropriate augmentation and Holter
33. Take home message
Gluckman et al.JACC 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults
