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EBM opinion and debate
General medicine
SARS-CoV-2 myocarditis: what physicians need to know
  1. Arsalan Khalil,
  2. Tamara Naneishvili,
  3. Neeraj Prasad,
  4. James Glancy
  1. Cardiology, County Hospital Hereford, Hereford, Herefordshire, UK
  1. Correspondence to Dr Arsalan Khalil, Cardiology, County Hospital Hereford, Hereford HR1 2BN, UK; arsalan.khalil{at}nhs.net

http://dx.doi.org/10.1136/bmjebm-2020-111527

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    Introduction

    Myocarditis is one of the complications seen with viral infections like parvovirus B19, human herpes virus, Epstein-Barr virus, cytomegalovirus, adenovirus and enteroviruses. Recent data suggest that SARS-CoV-2 could be a possible aetiological agent for myocarditis in the current pandemic.1 Although we have some understanding of its respiratory manifestations, limited data are available regarding the involvement of the heart with this virus.

    Myocarditis secondary to SARS-CoV-2 has been reported as one of the causes of increased mortality.1 The European Society of Cardiology (ESC) states ‘in the absence of vaccines or curative medical treatment, SARS-CoV-2 exerts an unprecedented global impact on public health and healthcare delivery’.2

    In this article, we outline the pathophysiology, clinical manifestations, investigations and some of the treatment modalities that have been used so far for the management of SARS-CoV-2-related myocarditis. We also suggest areas for further research.

    What do we know so far?

    Multiple case reports have described SARS-CoV-2-related myocarditis.3–5 However; there are no randomised controlled trials or meta-analysis on this subject.

    Proposed mechanisms for injury to the myocardium include binding of SARS-CoV-2 spike protein to ACE 2 which facilitates virus entry into the target cells,6 immune-related myocardial inflammation and direct injury to the myocardium caused by hypoxemia.7 Furthermore, it has also been suggested that IL-6 plays an integral role in activation of helper T cells, which in turn release inflammatory cytokines ultimately resulting in myocardial inflammation and damage.8

    Age distribution and clinical presentation of SARS-CoV-2-related myocarditis is variable. Clinical manifestations can be as mild as fatigue and shortness of breath to devastating …

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    Footnotes

    • Contributors AK—Internal Medicine Trainee—involved in conceptualisation, data collection, analysis, literature review, article writing and proof reading. TN—Cardiology Registrar—involved in conceptualisation, data collection, analysis, literature review, article writing and proof reading. NP—Cardiology Consultant involved in conceptualisation, review and editing of the article, and overall supervision. JG—Cardiology Consultant involved in conceptualisation, review and editing of the article and overall supervision.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.