What Symptoms Should Raise Concern for COVID-19-Related Myocarditis? Insights from Dr. Liu Xingpeng on Haodf Online

Can COVID-19 infection trigger myocarditis? Can its occurrence be prevented? How can it be identified early? Which populations need to pay special attention? How should one effectively manage myocarditis after diagnosis?

Recently, in response to widespread public concern about COVID-19-associated myocarditis, Haodf Online invited Dr. Liu Xingpeng, Deputy Director of the Heart Center and Director of the Arrhythmia Division at Beijing Chaoyang Hospital, to address questions from the public through a live video stream. Below are Dr. Liu’s insights and selected frequently asked questions.

Liu Xingpeng, Deputy Director of the Heart Center and Director of the Arrhythmia Department at Beijing Chaoyang Hospital

Question: Can the novel coronavirus cause myocarditis? Does it warrant attention?

Yes. There is a medical condition known as viral myocarditis. Viruses are pathogens that can directly cause inflammation of the myocardium. Since SARS-CoV-2 is a virus, it can naturally lead to myocarditis as well. The primary organ targeted by SARS-CoV-2 is the respiratory system, followed by the heart. Studies have shown that nearly 30% of hospitalized patients with COVID-19 exhibit myocardial injury. However, myocardial injury is not equivalent to myocarditis. Even if cardiac biomarkers show abnormalities, particularly mild ones, this does not necessarily indicate myocarditis.

Overall, SARS-CoV-2-associated myocarditis is relatively uncommon in clinical practice. Among hospitalized patients with COVID-19 abroad, the proportion diagnosed with SARS-CoV-2-induced myocarditis is approximately 1%. From this perspective, it is not particularly alarming; however, why should it be taken seriously? Data published internationally indicate that the mortality rate of SARS-CoV-2-associated myocarditis can reach over 10%, which remains substantially high. Why? Because a subset of cases presents as fulminant myocarditis, which is highly aggressive and perilous, characterized by rapid clinical deterioration and swift disease progression. Moreover, affected patients are predominantly young individuals. Therefore,While there is no need for excessive alarm given the overall low incidence rate, it is important to remain vigilant, as the consequences can sometimes be severe once it occurs.

Question: How to Identify COVID-19 Myocarditis? What Are the Symptoms?

SARS-CoV-2-associated myocarditis predominantly affects young and middle-aged adults, with cases in individuals over 60 years of age being relatively rare. Symptoms such as chest tightness, fatigue, shortness of breath, exertional dyspnea, and palpitations are non-specific and may indicate either cardiac or pulmonary pathology. However, the following manifestations warrant particular attention:

First, the disease course is prolonged, and symptoms have remained persistently unresolved.If you experience shortness of breath, severe palpitations, extreme fatigue, or even low blood pressure upon exertion, and these symptoms persist without relief, you must seek medical attention at a hospital.

Second, symptoms improved after fever onset due to COVID-19, but worsened again after a period of time.At this point, it is necessary to consult a physician to determine the underlying cause.

Third, syncope occurs.There are two types of syncope: one is characterized by a sense of losing control, requiring the patient to hold onto nearby objects for support, but consciousness is regained immediately upon falling; this type may be related to blood pressure. The other type involves a sudden collapse, where the patient falls abruptly without warning. This latter scenario warrants high alertness, as myocarditis can sometimes involve the cardiac conduction system, leading to conduction block and subsequent syncope.

Fourth, rapid heartbeat.During a fever, the heart rate typically increases. However, if the fever has subsided but the heart rate remains above 100 beats per minute, or if peripheral capillary oxygen saturation (SpO2) has returned to normal and all pulmonary symptoms have resolved yet tachycardia persists, cardiac issues should be given serious consideration.

Fifth, significant worsening of fatigue.If fatigue is particularly severe when lying flat and only improves with the head elevated on pillows or in a sitting position, accompanied by noticeable ankle swelling, this indicates heart failure. Cardiac function should be evaluated at this point, as myocarditis can lead to impaired cardiac function.

Q: When does COVID-19-associated myocarditis typically occur?

Approximately 70% of individuals develop myocarditis during the course of a SARS-CoV-2 infection, while another subset develops it after recovery, following a latent period. International statistics indicate that this latter scenario accounts for more than 20% but less than one-third of cases. On average, it takes 50 days for the body to recover after testing negative. It is advisable to ensure adequate rest and maintain a balanced diet and healthy lifestyle.

Question: What relevant tests can be performed?

First, blood tests are conducted to check for markers of myocardial injury, such as cardiac troponin I (TNI). Levels will rise if there is myocardial injury, but in most cases, the elevation is not significant unless you have developed particularly severe myocarditis. Additionally, elevated levels of indicators such as C-reactive protein and interleukins also indicate the presence of inflammation in the body.

Second, cardiac magnetic resonance imaging (CMR) can detect myocardial edema; its presence indicates inflammation.

Third, echocardiography. While echocardiography cannot directly visualize inflammation itself, it can detect sequelae of myocarditis, such as cardiac enlargement and pericardial effusion.

Question: How is myocarditis caused by the novel coronavirus treated?

For patients with mild myocarditis, there is no specific treatment; the management is not significantly different from that of pneumonia. However, in cases of severe myocarditis, such as fulminant myocarditis, every second counts in resuscitation efforts, and extracorporeal membrane oxygenation (ECMO) may even be required. If the patient is young and the condition is identified promptly, the likelihood of successful resuscitation remains high. Conversely, if diagnosis is delayed or the treating hospital lacks the necessary resources, the outcome is often regrettable.

Question: How to prevent COVID-19-associated myocarditis?

There is currently no medical evidence to support the use of medications for prevention. After testing positive, individuals should prioritize rest, particularly during the first month, and avoid strenuous exercise. Both aerobic and anaerobic activities can significantly increase cardiac burden.Ensure adequate nutrition, get sufficient rest, and maintain a positive mood; this is more effective.

Other Popular Q&A:

Question: Does undergoing heart surgery increase the risk of developing myocarditis?

Not necessarily; it still depends on immune function. For individuals with coronary heart disease, those who have undergone valve replacement, radiofrequency ablation, or stent implantation, there is no need for excessive concern as long as initial treatment has been properly managed.

Q: Are individuals with a history of myocarditis more susceptible?

Patients with a history of myocarditis should remain vigilant. In cardiology, there is a well-established pattern whereby individuals who have suffered from a particular condition are at a significantly higher risk of recurrence. Since the majority of myocarditis cases are viral in origin, this indicates a susceptibility of the heart to viral invasion, warranting close attention. Furthermore, recurrent episodes of myocarditis can lead to extensive myocardial scarring, which may subsequently result in cardiac dysfunction and heart failure. Clinically, a substantial proportion of dilated cardiomyopathy cases evolve from unresolved myocarditis. Additionally, although the extent of myocardial inflammation may sometimes be limited, the involvement of critical anatomical sites can be particularly dangerous. For instance, inflammation affecting the main conduction pathway between the atria and ventricles can cause cardiac arrest, leading to severe and potentially life-threatening consequences.

Although there is not substantial evidence proving that this population is particularly susceptible, common sense suggests that their risk is higher than that of individuals who have never been affected.

Q: What precautions should heart disease patients take regarding medication?

Conditions such as fever, pneumonia, and hypoxia can all impact our heart health. Everyone should pay attention to the following issues:

First, fever. Fever increases the burden on the heart; I recommend lowering the temperature as early as possible, which is very important.

Second, when treating pneumonia, adjustments to cardiac medications are sometimes necessary. For example, while Pfizer’s Paxlovid is effective as an early antiviral therapy, it interacts adversely with anticoagulants such as rivaroxaban, which are commonly used by many patients with heart disease.For individuals with heart disease who contract COVID-19, it is advisable to consult a cardiologist regarding potential drug interactions.

Third, cardiac patients are particularly concerned about two issues: heart rate and blood pressure. Many patients may experience elevated blood pressure and increased heart rate after infection, which exacerbates the burden on the heart and may precipitate angina pectoris. In such cases, adjustments to cardiac medications may be necessary; however, patients are advised against making unauthorized adjustments and should consult a professional cardiologist.

Q: On the fourth day of testing positive, my temperature has returned to normal, but I occasionally experience chest pain. Is this related to myocarditis?

This is particularly common in clinical practice. However, myocarditis rarely presents with severe chest pain; significant pain typically occurs only when the inflammation extends to the pericardium, causing pericarditis, which results in sharp pain upon inspiration. Apart from this, chest pain is uncommon. Therefore,Chest pain is not a primary concern in myocarditis.

Let’s clarify the so-called “chest pain.” Many people worry about angina. What exactly is angina? Pain can be assessed along several dimensions. First, consider the area affected: if the painful region is about the size of a palm, it may indicate a cardiac issue; however, if the pain is localized to an area as small as a fingertip—very limited and well-defined—it is generally not angina. Second, consider the duration: if the pain lasts only a second, it is typically not angina. True cardiac pain tends to last longer, though not continuously for one or two days; episodes lasting several minutes, ten-plus minutes, or even dozens of minutes can occur. Here, I have merely highlighted a few distinguishing features. If you experience symptoms, you should consult a physician to determine whether they are cardiac-related. Based on the question described—occasional brief pains on the fourth day after testing positive for COVID-19—the likelihood of myocarditis is low.