Myocarditis and Pericarditis After COVID-19 Vaccination: Clinical Management Guidance for Healthcare Professionals

Overview

This specialist Guidelines summary covers clinical guidance to support the detection and management of clinical cases of myocarditis and pericarditis associated with COVID-19 vaccination.

The guidance on which this summary is based was produced by the UK Health Security Agency (UKHSA) in partnership with the Royal College of General Practitioners and the Royal College of Emergency Medicine, and is endorsed by the British Congenital Cardiac Association.

This is a summary for secondary care cardiology teams. For further information, refer to the full guideline.

Background to Myocarditis and Pericarditis after COVID-19 Vaccination

• Myocarditis or pericarditis are very rare conditions following vaccination
• Most patients who develop symptoms do so within a week of vaccination
• Patients who develop symptoms have usually been vaccinated with an mRNA vaccine (Pfizer/BioNTech or Moderna)
• Myocarditis and pericarditis following vaccination is usually mild or stable, and patients typically recover fully without medical treatment
• A very small number of those with myocarditis have been admitted to hospital
• In two studies from the US, significant left ventricular fibrosis has been described in a high percentage of those children admitted to hospital, with a small percentage of these having non-sustained ventricular tachycardia
• No long-term follow-up data are available yet on hospitalised patients.

Recommendations for Paediatric Patients

The following recommendations are for paediatric patients in the context of recent COVID-19 vaccination (within 10 days).

For information on initial presentation and referral to secondary care, see the full guideline.

Investigations

• Hospital investigations should follow local myocarditis or pericarditis guidelines with the involvement of the regional paediatric cardiology team
• If there is a suspicion of myocarditis or pericarditis, initial investigations should be:
  • 12-lead electrocardiogram (ECG)
  • inflammatory blood markers (C-reactive protein [CRP], full blood count [FBC], and erythrocyte sedimentation rate [ESR])
  • troponin
• If abnormal ECG or troponin, discuss with the paediatric cardiology team for further management plan, including cardiac imaging (echocardiogram, cardiovascular magnetic resonance imaging [MRI]) and rhythm monitoring (24-hour Holter, stress ECG)
• Further investigations and follow-up should be led by the regional paediatric cardiology team.

Recommendations for Adults Aged 18–40 Years

The following recommendations are for adults aged 18–40 years in the context of recent COVID-19 vaccination (within 10 days).

For information on initial presentation and referral to secondary care, see the full guideline.

Investigations in Secondary Care

• If there is a suspicion of myocarditis or pericarditis, the initial investigations should be:
  • 12-lead ECG
  • inflammatory blood markers (CRP, FBC, and ESR)
  • troponin
• If ECG or troponin are abnormal, discuss with the cardiology team for further management plan, which might include cardiac imaging (echocardiogram, cardiovascular MRI) and rhythm monitoring (24-hour Holter, stress ECG)
• Further investigations and follow-up should be led by the regional cardiology team.

Further Follow-Up (All Ages)

• All patients that did not require referral to hospital in initial presentation should be:
  • given the following ‘safety netting’ advice: ‘if symptoms persist or worsen within 5 days, they should return to their GP for review’
  • referred for further investigation if, when seen later, they have concerning features including general clinical concern
• Patients requiring outpatient follow-up should be referred to cardiology and an assessment undertaken within 4 weeks.

Further Vaccination

• Patients that have been diagnosed with confirmed myocarditis following COVID-19 infection or vaccination should be treated following published guidelines for children and adults
• Cardiology follow-up should include a review 8 weeks after diagnosis to assess eligibility for further vaccinations
• For those that experience myocarditis or pericarditis within 2 weeks of the first dose of an mRNA vaccine, testing for nucleocapsid (N) antibody may indicate prior exposure to COVID-19. These individuals are likely to be well protected and therefore the benefit from a second or subsequent dose is likely to be more limited
• In circumstances where a further dose is considered necessary, for example in those at higher risk of the complications of COVID-19 infection, a second or booster dose of Pfizer/BioNTech vaccine should be considered once the patient has fully recovered. Emerging evidence suggests that an interval of at least 12 weeks should be observed from the previous dose
• If there is evidence of ongoing effects of acute or subacute myocarditis, then an individual risk–benefit assessment should be undertaken in consultation with the patient or their parents or guardians prior to offering further doses of COVID-19 vaccine.

Activity Following Vaccination

This advice applies to both adults and children:

• If the individual feels well after receiving their COVID-19 vaccination, there is no need to pre-emptively restrict physical activity post vaccination, and individuals can continue with their pre-existing level of physical activity
• In the unlikely event that they experience chest pain, palpitations, unexpected shortness of breath, or fainting, they should seek medical attention and should be investigated and managed according to these guidelines. Strenuous physical activity should be avoided until symptoms improve
• If an individual has been diagnosed with myocarditis or pericarditis, advice on exercise should be given by a qualified healthcare professional (for example, cardiologist, sports cardiologist, or sports medicine physician) and should follow clinical guidelines on when to resume activity or competitive sports.