COVID-19 related myocarditis: a systematic review and overview

Abstract

Background: Coronavirus 2019 (COVID-19) infection was first noted in China (Wuhan) in 2019.1 Initially, COVID-19 infection was considered to be a viral illness with respiratory manifestations only,2 but further studies and the findings from them suggest that severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) is also increasingly expressed in cardiac myocytes. Such infection may result in cardiac manifestations leading to myocardial inflammation and myocarditis.3 Aims and objectives: The frequency and prognostic impact of COVID-19-related myocarditis are still unknown. This systematic review demonstrates recent evidence regarding detailed assessment of signs and symptoms; diagnostic modalities, including laboratory investigations and cardiac imaging; and the clinical outcome of patients presenting or admitted with COVID-19-related myocarditis to help clinicians considering it as an important differential. Method(s): In accordance with Preferred Reporting Systems for Systematic reviews and Meta-analyses (PRISMA) 2020 guidelines, a systematic review was carried out using PubMed, PubMed Central (PMC), Cochrane Central, Web of Science and Google Scholar from 2019 until December, 2021.4 A combination of the keywords 'SARS-CoV-2', 'COVID-19' and 'myocarditis' was used. Case reports and cohorts of patients with a definite diagnosis of myocarditis resulting from COVID-19 were included. The findings were presented in tabulated form and charts. Result(s): In total, 55 case reports, five cohorts and four systematic reviews were identified, comprising 216 patients. The most common pre-existing medical condition was hypertension (52%), followed by diabetes (46%) and other cardiovascular issues, including hyperlipidaemia, ischaemic heart disease and atrial fibrillation (15% in total). The majority of the patients presented with the complaints of cough, fever, shortness of breath and chest pain, with proportions of 62%, 60%, 53% and 44%, respectively. Inflammatory markers were raised in most of the patients (98%), while cardiac biomarkers were elevated in 95%. Keeping in view the radiological findings, cardiomegaly was the most common finding noted in nearly one-third of the patients. Electrocardiography (ECG) showed ST elevation in 45% of the patients, while 7% exhibited T wave inversions. Cardiovascular magnetic resonance imaging (CMR) revealed 83% of the patients to have myocardial oedema, with late gadolinium enhancement (LGE) in nearly two-thirds of the patients.5 Inpatient management comprised azithromycin (25%), methylprednisolone or steroids (9%) and other standard care treatments for COVID-19 infection. Acute respiratory distress syndrome (ARDS) was the most common in-hospital complication (66%) in nearly two-thirds of the patients, followed by cardiogenic shock (14%). On the last follow-up and assessment, 65% of the patients had survived, while 32% of the patients had not, and the remaining 3% were in intensive treatment units (ITUs). Conclusion(s): It is imperative to demonstrate and demarcate COVID-19 infection and cardiac manifestation, particularly myocarditis presentations, because of the increased risk of mortality among patients contracting both myocardial inflammation and ARDS. With the help of diagnostic modalities and various treatment options available for COVID-19 and cardiac manifestation (myocarditis), patients who are high risk and have strong suspicion for COVID-19-related myocarditis must be appropriately diagnosed and promptly treated to limit co-infections.Copyright © 2025