Acute pericarditis as a major clinical manifestation of long COVID-19 syndrome 2022 Dini et al

[Andy]

Highlights

• Acute pericarditis is an important manifestation of long COVID-19 syndrome.
• Thickened and bright pericardial layers with small effusions was the most frequent finding.
• History of autoimmune and allergic disorders, and palpitations/arrhythmias were risk factors.

Abstract

Background
The long COVID-19 syndrome has been recently described and some reports have suggested that acute pericarditis represents important manifestation of long COVID-19 syndrome. The aim of this study was to identify the prevalence and clinical characteristics of patients with long COVID-19, presenting with acute pericarditis.

Methods
We retrospectively included 180 patients (median age 47 years, 62% female) previously diagnosed with COVID-19, exhibiting persistence or new-onset symptoms ≥12 weeks from a negative naso-pharyngeal SARS CoV2 swamp test. The original diagnosis of COVID-19 infection was determined by a positive swab. All patients had undergone a thorough physical examination. Patients with suspected heart involvement were referred to a complete cardiovascular evaluation. Echocardiography was performed based on clinical need and diagnosis of acute pericarditis was achieved according to current guidelines.

Results
Among the study population, shortness of breath/fatigue was reported in 52%, chest pain/discomfort in 34% and heart palpitations/arrhythmias in 37%. Diagnosis of acute pericarditis was made in 39 patients (22%). Mild-to-moderate pericardial effusion was reported in 12, while thickened and bright pericardial layers with small effusions (< 5 mm) with or without comet tails arising from the pericardium (pericardial B-lines) in 27. Heart palpitations/arrhythmias (OR:3.748, p = 0.0030), and autoimmune disease and allergic disorders (OR:4.147, p = 0.0073) were independently related to the diagnosis of acute pericarditis, with a borderline contribution of less likelihood of hospitalization during COVID-19 (OR: 0.100, p = 0.0512).

Conclusion
Our findings suggest a high prevalence of acute pericarditis in patients with long COVID-19 syndrome. Autoimmune and allergic disorders, and palpitations/arrhythmias were frequently associated with pericardial disease.

Open access, https://www.internationaljournalofcardiology.com/article/S0167-5273(22)01891-5/fulltext

 

[SNT Gatchaman]

I was curious about use of the term acute pericarditis given that this was being diagnosed in patients with established LC and, I assumed, not necessarily short / self-limiting.

Thirty-nine (22%) patients fulfilled the criteria for acute pericarditis according to ESC guidelines. Twenty-eight presented two classical criteria; 10 with three criteria and one with four criteria for pericarditis.

The ESC guidelines are published as: 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC).

Acute pericarditis is an inflammatory pericardial syndrome with or without pericardial effusion.

The term ‘incessant’ has been adopted for cases with persistent symptoms without a clear-cut remission after the acute episode. The term ‘chronic’ generally refers—especially for pericardial effusions—to disease processes lasting >3 months. The Task Force suggests that the term ‘acute’ should be adopted for new-onset pericarditis, ‘incessant’ for pericarditis with symptoms persisting for >4–6 weeks (that is generally the approximate length of conventional anti-inflammatory therapy and its tapering), and ‘chronic’ for pericarditis lasting >3 months.

 

[SNT Gatchaman]

Some snippets from the discussion —

It is well known that pericarditis is among the most frequent cardiac complications after viral infections. Case reports have recently documented pericarditis with or without pericardial effusion as delayed complications of COVID-19, but the real prevalence of pericarditis in long COVID-19 patients is still unknown.

In our study, diagnosis of delayed cases of acute pericarditis was based on the presence of at least two of the following criteria: typical sharp and positional chest pain, presence of pericardial effusion of any degree, and electrocardiographic changes. Most study patients diagnosed with acute pericarditis showed thickened and bright pericardial layers with small or negligible effusion. Pericarditis was diagnosed in patients with thickened pericardium albeit no signs of effusion, only in the presence of typical chest pain and electrocardiographic alterations. The association with typical chest pain, electrocardiographic changes and eventually the response to anti-inflammatory medications has also been helpful in substantiating the final diagnosis.

Although echocardiography is considered the standard cardiac imaging technique, inflammation of the pericardial layers may not always be easily detected by [transthoracic echocardiograph]. Cardiovascular magnetic resonance (CMR) can provide comprehensive information on pericardial disease, including assessment of pericardial thickness and small or negligible effusions. In patients recovered from COVID-19, CMR studies performed more than two months after the infection have shown that as many as 78% had cardiac involvement with abnormal findings, while signs of ongoing myocardial inflammation were present in 60%.

Recently, cardiovascular complications have been also reported from COVID-19 vaccines and this may suggest common pathways shared by the untoward effects of anti-SARS CoV2 vaccination and the manifestations of the long COVID-19 syndrome.

Several mechanisms have been proposed to explain the occurrence of the long COVID-19, including ongoing inflammation activated by the virus and host of factors comprising allergic conditions, autoimmune reactions, and vascular injury caused by hypercoagulability and thrombosis. It has been recognized that inadequate or excessive immune response driven by T and B cell-mediated mechanisms may be implicated in the occurrence of pericarditis and myocarditis after viral infections. Our finding of more frequent occurrence of pericarditis in patients presenting [a] history of autoimmune and allergic disorders suggests that an association might be present between the two conditions and that the immune system continues to over-react after the coronavirus infection and is unable to reset itself to idle.