Myocarditis

 

Inflammation of the heart muscle (myocardium) is most commonly caused by viral infections. Its symptomatic presentation can greatly vary. Mild fatigue and malaise on the light end but ranging to chest pain, arrhythmias, and rarely cardiogenic shock and death. Coxsackievirus, parvovirus, and herpes were the usual culprits, but positively identifying the cause of the inflammation would prove elusive in most cases. Drugs can also be the source; referred to as toxic myocarditis, the offending agent can range from cocaine to prescription products like lithium, phenothiazines, and tricyclic antidepressants. Myocarditis is certainly associated with COVID infection. One study showed 30% of patients had signs of myocarditis with cardiac imaging. Rarely it comes as a side effect of vaccination. It is a serious condition that needs to be identified and treated quickly. Chronic myocarditis over time may lead to anatomic changes in the heart muscle that predispose the patient to ventricular dysrhythmias.

The definitive diagnosis for myocarditis would be an EMB (endomyocardial biopsy). That procedure can be a bit intrusive on living patients. Even though it can be done safely, it is not without risk. So most commonly done to aid in diagnosis is the ECG or EKG electrocardiogram, which will reveal sinus tachycardia and ST segment and T wave changes. Further imaging studies like an echocardiogram or a cardiac MRI can help confirm the diagnosis. Elevated biomarkers that can indicate myocarditis include troponin, C reactive protein, creatine kinase, and white blood cells.

Multiple case reports and further reviews of the VAERS (vaccine adverse event reporting system) have confirmed myocarditis and pericarditis are rare but real side effects associated with the messenger RNA, or mRNA, vaccination. The most common side effects of the mRNA vaccines also correlate nicely with mild myocarditis symptoms. Finland, Sweden, and Denmark have all limited the use of the Moderna vaccine in younger males due to this concern. These patients were offered the Pfizer product instead. Just recently, the Food and Drug Administration cut the booster dose for Moderna in half. Last week, the FDA also failed to approve the Moderna vaccine for the 12-17 age group, delaying the decision until January. Some authors have argued we should be increasing the time between the two doses to help prevent these complications. I have been encouraging this myself in practice. I waited two months between mine.

Still, the overwhelming guidance from multiple health agencies insists the risks of vaccination are outweighed by their benefits. This is true but should be further stratified for a young male who has already had COVID and successfully recovered without issue; there is little benefit, meanwhile the risks remain. We are forcing vaccination on a patient population that arguably needs it the least but who ironically may suffer the worst complications from it. The evidence we have thus far likely underestimates the actual amount of myocarditis occurring due to vaccination. For a small subset like athletes, the theoretical risk could be greater. The average patient may not be bothered by a little heart inflammation, but athletes who push their cardiovascular systems to the limit rightfully should have concerns. The cardiovascular complications with COVID seem to be related to an indirect inflammatory state, not the viral infection itself. Because of this, I also advise patients to take it easy after their vaccination and limit physical activity. Not a concern for most of my patients who remind me taking it easy is their job. For younger ones, though, I would advise skipping football or soccer practice for a week after vaccination.

Treatment of acute myocarditis should include oxygen supplementation and optimizing the fluid status. Diuretics and epinephrine may also be necessary in patients who already have congestive heart failure. NSAIDS should be avoided since they impede the healing of the myocardium. Supportive care and preservation of left ventricular function are the goal, and anticoagulation therapy may be necessary. Upon discharge, a low-salt diet should be started and physical activity avoided in the short term and ramped up slowly when appropriate.

Jacob Hyatt Pharm D.
Father of three, pharmacist, Realtor, landlord, independent health and medicine reporter
https://substack.com/discover/pharmacoconuts

hyattjn@gmail.com

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Further Reading and References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC152844/

Ansari A, Maron BJ, Berntson DG. Drug-induced toxic myocarditis. Tex Heart Inst J. 2003;30(1):76-79.

Kang M, An J. Viral Myocarditis. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459259/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8548171/

Onderko L, Starobin B, Riviere AE, et al. Myocarditis in the Setting of Recent COVID-19 Vaccination. Case Rep Cardiol. 2021;2021:6806500. Published 2021 Oct 19. doi:10.1155/2021/6806500

https://www.ajronline.org/doi/10.2214/AJR.21.26853

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8541143/

Hajjo R, Sabbah DA, Bardaweel SK, Tropsha A. Shedding the Light on Post-Vaccine Myocarditis and Pericarditis in COVID-19 and Non-COVID-19 Vaccine Recipients. Vaccines (Basel). 2021;9(10):1186. Published 2021 Oct 15. doi:10.3390/vaccines9101186

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8539812/

Lv M, Luo X, Shen Q, et al. Safety, Immunogenicity, and Efficacy of COVID-19 Vaccines I n Children and Adolescents: A Systematic Review. Vaccines (Basel). 2021;9(10):1102. Published 2021 Sep 29. doi:10.3390/vaccines9101102

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8529544/

Riedel PG, Sakai VF, Castro Cardoso Toniasso S, et al. Heart failure secondary to myocarditis after SARS-CoV-2 reinfection: a case report [published online ahead of print, 2021 Oct 21]. Int J Infect Dis. 2021;S1201-9712(21)00822-5. doi:10.1016/j.ijid.2021.10.031

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8533153/

Skrzypiec-Spring M, Sapa-Wojciechowska A, Haczkiewicz-Leśniak K, et al. HMG-CoA Reductase Inhibitor, Simvastatin Is Effective in Decreasing Degree of Myocarditis by Inhibiting Metalloproteinases Activation. Biomolecules. 2021;11(10):1415. Published 2021 Sep 28. doi:10.3390/biom11101415

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8541609/

Arévalos V, Ortega-Paz L, Rodríguez-Arias JJ, et al. Acute and Chronic Effects of COVID-19 on the Cardiovascular System. J Cardiovasc Dev Dis. 2021;8(10):128. Published 2021 Oct 5. doi:10.3390/jcdd8100128

https://smw.ch/article/doi/smw.2021.w30087

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524235/

Choi S, Lee S, Seo JW, et al. Myocarditis-induced Sudden Death after BNT162b2 mRNA COVID-19 Vaccination in Korea: Case Report Focusing on Histopathological Findings. J Korean Med Sci. 2021;36(40):e286. Published 2021 Oct 18. doi:10.3346/jkms.2021.36.e286

Published in Healthcare
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There are 61 comments.

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  1. Bryan G. Stephens Thatcher
    Bryan G. Stephens
    @BryanGStephens

    Good information

    • #1
  2. Doctor Robert Member
    Doctor Robert
    @DoctorRobert

    I have seen a patient with vaccine-induced myocarditis.  I practice half time. 

    His physician had not reported the case to VAERS.  You can be certain that I did.

    Data on adverse reactions after these vaccines are quite unreliable, the majority of cases will not be reported.

    • #2
  3. Richard Easton Coolidge
    Richard Easton
    @RichardEaston

    If you’re under 40 without comorbidities, the vaccines are almost certainly more risky than COVID. Heck, that’s probably the case if you’re 65 and under. The CDC is incompetent and corrupt. Note that several people quit when the vaccines were OKd for the young.

    • #3
  4. DonG (CAGW is a hoax) Coolidge
    DonG (CAGW is a hoax)
    @DonG

    Jacob, your writing is both informative and interesting.   Thank you for preparing and sharing.  I am curious about the statement below.  Does “T wave changes” imply that you need a baseline EKG beforehand?  

    JacobHyatt: So most commonly done to aid in diagnosis is the ECG or EKG electrocardiogram which will reveal sinus tachycardia and ST segment and T wave changes. 

     

    • #4
  5. The Reticulator Member
    The Reticulator
    @TheReticulator

    JacobHyatt:  Some authors have argued we should be increasing the time between the two doses to help prevent these complications.  I have been encouraging this myself in practice, I waited two months between mine.

    I thought the main reason to increase the time between doses was because doing so produces a stronger, longer-lasting response from one’s immune system.  This bit about the timing’s effect on myocarditis is a new one on me. Is the idea to give one’s body time to recover from the first dose before getting another?  

     

    • #5
  6. The Reticulator Member
    The Reticulator
    @TheReticulator

    JacobHyatt: Not a concern for most of my patients who remind me taking it easy is their job, for younger ones though I would advise skipping football or soccer practice for a week after vaccination.

    It certainly never occurred to me to do that.  I just now looked it up and see that I did a 22 mile  bicycle ride two days after my booster, and that I posted some better-than-usual times on my routes in the first 3 days after my booster.

    When I got my first shots it was winter and I was riding indoors.  My training diary in Rouvy tells me I kept up my usual schedule of rides, including hour-long rides the evening of each day I got a shot.  My indoor rides are generally a lot more work than outdoor rides of the same length, and these appear to have been no exception.  Like I say, it just never occurred to me to change my usual routine.

    But then, I’m an old guy, not a young one. 

    Which reminds me that a few weeks ago on a bicycle touring forum, one of our members announced that he was probably done with bicycle touring for good. He had hoped to do at least one more thousand mile tour, but his covid shots had taken his strength away, and he thought he’d most likely have to stick to rides close to home from now on.  I’ve not known anyone else who had such a serious effect from the vaccine, though a couple of my adult kids were knocked back by their shots for a day or two. (This guy had also told us that he had turned 90, which was a big surprise to most of us, who had thought he was 20 years younger than that. A lot of us are in our 70s now.)  I wonder if it could have been myocarditis, even at that age.

     

    • #6
  7. Steven Seward Member
    Steven Seward
    @StevenSeward

    Please keep these posts coming, Jacob!  They may not stimulate heated debate like political discussions do, but they are wonderfully informative!

    • #7
  8. Tyrion Lannister Inactive
    Tyrion Lannister
    @TyrionLannister

    How long after getting the moderna vaccine typically would one experience myocarditis?  My grandmother had a weak heart and a couple weeks after getting the vaccine had a stroke and was airlifted to the hospital. I’ve suspected the shot was the cause, but it’s hard to tell because she has been in poor health.  

    • #8
  9. drlorentz Member
    drlorentz
    @drlorentz

    JacobHyatt: Still, the overwhelming guidance from multiple health agencies insists the risks of vaccination are outweighed by their benefits.

    It may be true that this is the “overwhelming guidance” but that doesn’t make the guidance accurate. As Sharyl Attkisson has documented, the CDC has intentionally misrepresented numerous facts about COVID-19 and the related vaccines. The fact that “multiple agencies” agree is irrelevant; science is not a democracy.

    The risks of vaccination remain uncertain, while the benefits are minimal for many groups, as you subsequently noted. Reporting on VAERS is a poor estimator of adverse-effect incidence for obvious reasons, such as @DoctorRobert illustrated. It’s important to understand and highlight the asymmetry of our knowledge of risks vs. benefits. Furthermore, there seems to be little consideration of risks altogether. The CDC has now authorized the vaccination of children as young as 5 years old. It is difficult to see how this guidance accords with the claim that “the risks of vaccination are outweighed by their benefits.” 

    • #9
  10. Manny Coolidge
    Manny
    @Manny

    Why is there an increased risk in males rather than females?  Or am I reading into that?

    • #10
  11. Stina Inactive
    Stina
    @CM

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    There’s been speculation on that. Some think testosterone may have something to do with it. Most of the events have been in young males post puberty.

    My husband was researching the vaccines and Pfizer/Moderna have higher incidence with males while Jansen has higher among women. So he’s going with that one if forced.

    • #11
  12. Manny Coolidge
    Manny
    @Manny

    Stina (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    There’s been speculation on that. Some think testosterone may have something to do with it. Most of the events have been in young males post puberty.

    My husband was researching the vaccines and Pfizer/Moderna have higher incidence with males while Jansen has higher among women. So he’s going with that one if forced.

    Thanks.

    • #12
  13. Flicker Coolidge
    Flicker
    @Flicker

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    • #13
  14. Manny Coolidge
    Manny
    @Manny

    Flicker (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    I’m not sure I understood that last part. Testosterone plays a part in replicating the virus?

    • #14
  15. Stina Inactive
    Stina
    @CM

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    I’m not sure I understood that last part. Testosterone plays a part in replicating the virus?

    Men have been having worse outcomes than women.  

    https://pubmed.ncbi.nlm.nih.gov/33885345/

    • #15
  16. Flicker Coolidge
    Flicker
    @Flicker

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    I’m not sure I understood that last part. Testosterone plays a part in replicating the virus?

    That’s what I meant.  But I only I think so.  I’ll try to find it.

    • #16
  17. Manny Coolidge
    Manny
    @Manny

    Stina (View Comment):

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    I’m not sure I understood that last part. Testosterone plays a part in replicating the virus?

    Men have been having worse outcomes than women.

    https://pubmed.ncbi.nlm.nih.gov/33885345/

    That was interesting. I must have missed that over this past year. Of the five people I personally know that died from Covid, three were women and two men. But the women were all elderly while the men were 63 and 58.

    • #17
  18. Manny Coolidge
    Manny
    @Manny

    Flicker (View Comment):

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Why is there an increased risk in males rather than females? Or am I reading into that?

    Testosterone plays a part.

    Added: I haven’t looked it up lately, but I read maybe a year ago, before the male myocarditis, perhaps before the vaccine, that testosterone played a part in, I think, replication.

    I’m not sure I understood that last part. Testosterone plays a part in replicating the virus?

    That’s what I meant. But I only I think so. I’ll try to find it.

    Don’t bother Stina linked it. 

    • #18
  19. Flicker Coolidge
    Flicker
    @Flicker

    Manny (View Comment):

    Here is a bit from this study.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972673/

    ABSTRACT: COVID-19 consistently displays a higher mortality in males. This sex-specific difference in outcomes is seen not only in the current COVID-19 pandemic, but also in prior viral epidemics and pandemics. Sex hormones, such as testosterone, play a clear role in modulating the immune response, providing a clue that may illuminate the underpinnings of these outcomes. Developing a deeper understanding of these epidemiological findings permits a more effective response to the disease. This article summarizes the sex-specific COVID-19 outcomes, the role of androgens in generating these outcomes, and the potential role of modifying testosterone levels as a form of treatment of COVID-19.

    From section: Regulation of Viral Entry and Fusion

    While ACE-2 is considered essential for SARS-CoV-2 entry, evidence suggests that transmembrane protease serine 2 (TMPRSS2) cleaves the SARS-CoV-2 spike antigen, contributing to fusion with the host cell membrane.29 Androgens enhance the expression of TMPRSS2 and provide a further potential explanation for the higher susceptibility of men compared to women.30 One clue that provides insight into the androgen-driven nature of this protein is its recognized role in prostate cancer. TMPRSS2 is conventionally recognized as a contributor to prostate cancer development, with nearly half of all prostate cancers containing a translocation that places the TMPRSS2 regulatory element directly upstream from an oncogene.31 Since TMPRSS2 is regulated by androgens, this context allows the expression of androgens to drive oncogene expression.32 Although there is no evidence that TMPRSS2 is modulated by androgens in the lungs in a similar manner, a cell line model derived from lung tissue demonstrated an androgen-dependent regulation of TMPRSS2.33 If TMPRSS2 is indeed regulated by androgens in the lung, testosterone could help drive the higher SARS-CoV-2 infection rates by upregulating TMPRSS2. Overall, it appears that testosterone may enhance the expression of key cellular receptors that allow SARS-CoV-2 entry and fusion.

    Edited down.

    • #19
  20. Manny Coolidge
    Manny
    @Manny

    Flicker (View Comment):

    Manny (View Comment):

    Here is a bit from this study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972673/

    That’s also interesting.  Of course that leads to an obvious question: is estrogen a possible cure?  This is all a conspiracy to promote sex changes. :-P. 

    • #20
  21. Flicker Coolidge
    Flicker
    @Flicker

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Here is a bit from this study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972673/

    That’s also interesting. Of course that leads to an obvious question: is estrogen a possible cure? This is all a conspiracy to promote sex changes. :-P.

    I couldn’t really guess at that.  I edited my comment down to allow inclusion of the Abstract.

    • #21
  22. MiMac Thatcher
    MiMac
    @MiMac

    Richard Easton (View Comment):

    If you’re under 40 without comorbidities, the vaccines are almost certainly more risky than COVID. Heck, that’s probably the case if you’re 65 and under. The CDC is incompetent and corrupt. Note that several people quit when the vaccines were OKd for the young.

    Almost every study to date has noted that the risk of myocarditis is much higher from COVID than from the vaccines. Since everyone is expectoto either get the virus or get vaccinated, your risk is probably lower from the vaccine.

    • #22
  23. Richard Easton Coolidge
    Richard Easton
    @RichardEaston

    MiMac (View Comment):

    Richard Easton (View Comment):

    If you’re under 40 without comorbidities, the vaccines are almost certainly more risky than COVID. Heck, that’s probably the case if you’re 65 and under. The CDC is incompetent and corrupt. Note that several people quit when the vaccines were OKd for the young.

    Almost every study to date has noted that the risk of myocarditis is much higher from COVID than from the vaccines. Since everyone is expectoto either get the virus or get vaccinated, your risk is probably lower from the vaccine.

    How is it for people without comorbidities. Let’s face it, COVID is dangerous for the old, the obese and people with low Vitamin D levels.  Unless you adjust for these factors, you’ll get a wrong answer. And the government does not count deaths just after vaccination as vaccine deaths. GIGO. My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    • #23
  24. Stina Inactive
    Stina
    @CM

    Manny (View Comment):

    Flicker (View Comment):

    Manny (View Comment):

    Here is a bit from this study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972673/

    That’s also interesting. Of course that leads to an obvious question: is estrogen a possible cure? This is all a conspiracy to promote sex changes. :-P.

    Oh I wouldn’t mess with that. Such a horrible idea. But ivermectin was gaining a lot of positive attention prior to Covid as an effective antiviral because it blocked the virus’s ability to attach to a several different proteins that viruses use for replication. One is protease (which is one method Covid replicates), but it also inhibits TMPRSS2. This was from the NIH study on why Ivermectin could be an effective Covid treatment done by the NIH (and buried).

    If Covid is replicating on the TMPRSS in men and leading to higher viral load and worse outcomes, then the Pfizer pill (that only is listed as a protease inhibitor) would not be as effective in men if testosterone promotes the tmprss receptors. Ivermectin would have better results, targeting both proteins instead of just the 1.

    • #24
  25. The Reticulator Member
    The Reticulator
    @TheReticulator

    Richard Easton (View Comment):
    My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    Why not? Did no one report it to the VAERS database? 

    • #25
  26. Stina Inactive
    Stina
    @CM

    I see that TMPRSS is a protease. So I wonder why the NIH listed them separately… or is TMPRSS a specialized protease?

    • #26
  27. Stina Inactive
    Stina
    @CM

    The Reticulator (View Comment):

    Richard Easton (View Comment):
    My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    Why not? Did no one report it to the VAERS database?

    Who counts that? And it isn’t guaranteed that it would be.

    • #27
  28. The Reticulator Member
    The Reticulator
    @TheReticulator

    Stina (View Comment):

    The Reticulator (View Comment):

    Richard Easton (View Comment):
    My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    Why not? Did no one report it to the VAERS database?

    Who counts that? And it isn’t guaranteed that it would be.

    Well, if there seems to be a trend there is usually supposed to be a team of three people who evaluate each of the candidate entries to see if it counts as an adverse effect in the category they are studying. That’s part of how we know about the myocarditis issue, for example. So, no, no guarantee, because it depends on the effect that is being studied.  And I suppose they try to weed out bogus entries, too, but I don’t know how hard they do that, or what means are used. 

    • #28
  29. Richard Easton Coolidge
    Richard Easton
    @RichardEaston

    The Reticulator (View Comment):

    Richard Easton (View Comment):
    My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    Why not? Did no one report it to the VAERS database?

    See my thread

    https://ricochet.com/1087921/this-doctor-destroys-the-rationale-for-a-mandate/

    I think this slide from the doctor is accurate. I’m interested in hearing from anyone who thinks it is not.

    • #29
  30. The Reticulator Member
    The Reticulator
    @TheReticulator

    Richard Easton (View Comment):

    The Reticulator (View Comment):

    Richard Easton (View Comment):
    My friend who died of a heart attack the day after getting the second dose is not counted as a vaccination death.

    Why not? Did no one report it to the VAERS database?

    See my thread

    https://ricochet.com/1087921/this-doctor-destroys-the-rationale-for-a-mandate/

    I think this slide from the doctor is accurate. I’m interested in hearing from anyone who thinks it is not.

    I’ll lay my money on fake.  If it was some official CDC presentation, there would be context, maybe even a footnote citation. And an officially-sponsored CDC presentation wouldn’t be labeled U.S. CDC.  Also, it goes directly contrary to what the VAERS database is for. 

    • #30
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