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SARS-CoV-2, known as COVID-19, brought the world to a screeching halt nearly two and a half years ago. The emergent global collaboration resulted in enhanced understanding of the disease, fast-paced production of molecular and antibody-based assays to assist in management and finally, 10 different vaccines (Emergency Use Listing, WHO) to enable prevention.
Despite this, resumption of normalcy has been staggered with rapid emergence of a series of SARS-CoV-2 variants, currently Omicron, which has rendered some molecular assays ineffective and brought the efficacy of the vaccines into question. The unprecedented COVID-19 vaccine mandate, with mass vaccination worldwide for everyone five years or older, has brought to light previously unrecognised vaccine-related adverse events.
While primarily a respiratory infection, there is a bi-directional interaction between COVID-19 and the cardiovascular system, with the development of myocardial injury, arrhythmias, acute coronary venous syndrome (ACS) and venous thromboembolism with COVID-19 infection.
The life-threatening cardiovascular events noted with COVID-19 infection is in contrast to mild, self-limiting myocarditis/pericarditis associated with COVID-19 vaccine.
According to US Centers for Disease Control and Prevention, the incidence rates of myocarditis/pericarditis are ~12.6 cases per million doses of second-dose mRNA vaccines among 12-39 years of age, with a strong male predominance and occurs within days of vaccination.
Noting that the mortality from COVID-19 infection remains high (0.1 to 1 per 100,000 for the 12-29-year age group), the risk-benefit ratio is overwhelmingly in favour of the COVID-19 vaccination.
As our experience with the virus evolves, how does this knowledge impact our management of patients presenting with cardiovascular concerns?
Dr Michael Davis, Cardiologist
Cardiologists are seeing many people who, along with their GPs, have concerns that chest pain after COVID vaccination represents a myo/pericarditis, raising questions about having booster vaccinations.
Few of the many I have seen have a clear cardiac cause. Typical pericarditic pain is central anterior, pleuritic and exacerbated by lying flat and responds to anti-inflammatory agents. Usually after mRNA rather than other vaccines, the pain (and dyspnea, palpitation) comes on 1-5 days after (more commonly second dose) vaccination.
The diagnosis is confirmed by ECG, high sensitivity troponin, and possibly echocardiography.
ATAGI states that ‘further doses of an mRNA COVID-19 vaccine can be given to people who have been investigated for pericarditis but who had normal ECG, troponin and inflammatory markers, and who have been symptom-free for at least six weeks.
Dr Rajesh Kanna, Cardologist
Recently, we have seen a significant increase in patients seeking screening for cardiovascular disease.
With so much information about the recognised but rare side effects of COVID-19 vaccines on the cardiovascular system, patients are asking a lot of questions, which is translating to higher numbers of GP referrals and presentations to ED of young people having chest pain and palpitations after vaccine administration. This has led to increased demand for ECG, pathology and imaging.
But we have seen that the risk with COVID vaccines is very low, even amongst patients with symptoms.
We haven’t seen many patients during or post-COVID infection yet. We are hopeful that due to our current high vaccination rate, we will see a lower incidence of cardiac complications from the virus.
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