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COVID-19 and acute myocarditis: current literature review and diagnostic challenges

SUMMARY

INTRODUCTION

In the current literature, there has been an upsurge of cases of COVID-19-induced acute myocarditis. In this case-based review, we aimed to describe the clinical characteristics, imaging findings, and in-hospital course of acute myocarditis. In addition, the limitations of the myocarditis diagnosis were discussed since only fulminant myocarditis cases have been mentioned in the current literature.

METHODS

We performed a review of the literature of all patients who were diagnosed with COVID-19-induced acute myocarditis using the databases of PubMed, Embase, and the Cochrane.

RESULTS

16 case reports were found to be related to COVID-19-induced acute myocarditis. We observed that the ECG findings in most of the COVID-19 patients were non-specific, including diffuse ST-segment elevation, non-specific intraventricular conduction delay, sinus tachycardia, and inverted T-waves in anterior leads. Echocardiographic findings of COVID-19-induced acute myocarditis patients ranged from preserved left ventricular ejection fraction (LVEF) without segmental abnormalities to reduced LVEF with global hypokinesia. Interestingly, a few patients with COVID-19-induced acute fulminant myocarditis were steroid-responsive and had an amelioration with glucocorticoid and immunoglobulin therapy.

CONCLUSION

Despite the COVID-19 pandemic worldwide, a limited number of cases has been shared in the current literature. There are a lot of difficulties in the differential diagnosis of acute myocarditis in the context of COVID-19.

Coronavirus Infections; Betacoronavirus; Myocarditis; Cardiomyopathies

RESUMO

INTRODUÇÃO

Na literatura atual, houve um aumento dos casos apresentados com doença coronavírus de 2019 (COVID-19) induzida por miocardite aguda. Nesta revisão baseada em casos, buscamos descrever as características clínicas, achados de imagem e curso hospitalar de miocardite aguda. Além disso, as limitações em relação ao diagnóstico de miocardite foram discutidas, uma vez que apenas casos de miocardite fulminante foram mencionados na literatura atual.

MÉTODOS

Fizemos uma revisão da literatura de todos os pacientes diagnosticados com miocardite aguda induzida por COVID-19 com a utilização das bases de dados PubMed, Embase e Cochrane.

RESULTADO

Dezesseis casos relatados estão relacionados com a miocardite aguda induzida pela COVID-19. Observamos que os achados de ECG na maioria dos pacientes com COVID-19 não eram específicos, incluindo elevação difusa do segmento ST, atraso não específico da condução intraventricular, taquicardia sinusal e ondas T invertidas em pistas anteriores. Os resultados ecocardiográficos de doentes com miocardite aguda COVID-19 variaram entre a fração de ejeção ventricular esquerda preservada (LVEF) sem anomalias segmentais e a LVEF reduzida com hipocinésia global. Curiosamente, alguns pacientes com COVID-19 induzidos à miocardite aguda fulminante eram sensíveis aos esteroides e tinham uma melhoria com glucocorticoides e terapia com imunoglobulina.

CONCLUSÃO

Apesar da pandemia de COVID-19 em todo o mundo, um número limitado de casos tem sido compartilhado na literatura atual. Há muitas dificuldades para o diagnóstico diferencial de miocardite aguda no contexto da COVID-19.

Infecções por coronavírus; Betacoronavírus; Miocardite; Cardiomiopatias

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new variant form of coronavirus that is responsible for the coronavirus disease 2019 (COVID-19). On March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic after the confirmation of cases in five continents11. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. . Although the virus mainly infects the lung epithelial cells causing respiratory signs and symptoms, there has been an upsurge of cases that presented COVID-19-induced acute myocarditis. Currently, several mechanisms have been proposed to explain the underlying pathophysiology of COVID-19-related acute myocarditis22. Bavishi C, Bonow RO, Trivedi V, Abbott JD, Messerli FH, Bhatt DL. Acute myocardial injury in patients hospitalized with COVID-19 infection: a review. Prog Cardiovasc Dis. 2020;S0033-0620(20)30123-7. . It has been suggested that direct viral contact through angiotensin-converting enzyme 2 (ACE-2) signaling pathways might have a role in the myocardial injury33. Lang JP, Wang X, Moura FA, Siddiqi HK, Morrow DA, Bohula EA. A current review of COVID-19 for the cardiovascular specialist. Am Heart J. 2020;226:29-44. . In addition, cytokine release syndrome has been proposed to be the main pathophysiology of COVID-19-induced acute fulminant myocarditis33. Lang JP, Wang X, Moura FA, Siddiqi HK, Morrow DA, Bohula EA. A current review of COVID-19 for the cardiovascular specialist. Am Heart J. 2020;226:29-44. . In this case-based review, we aimed to describe the clinical characteristics, imaging findings, and in-hospital course of acute myocarditis as well as the limitations in regard to myocarditis diagnosis. In addition, we tried to identify the possible underlying mechanisms of COVID-19-related acute myocarditis, whether it is caused by direct viral damage or an inadequate host immune response.

METHODS

We performed a review of the literature of all patients who were reported to have COVID-19-induced acute myocarditis using the databases of PubMed, Embase, and the Cochrane. All databases were searched in June 2020 using the following keywords: ‘’COVID-19, acute myocarditis’ and ‘COVID-19, acute myopericarditis’. In total, 16 case reports were found to be related to COVID-19-induced acute myocarditis. Despite the fact that neither endomyocardial biopsy (EMB) nor cardiac magnetic rezones imaging (CMR) have been performed in several reports, the cases reported under the title of acute myocarditis were included in order to provide the current circumstance in terms of acute myocarditis in the COVID-19 era.

Baseline clinical characteristics

Tables 1 and 2 summarize the clinical characteristics of COVID-19-induced acute myocarditis patients44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6.

5. Kim IC, Kim JY, Kim HA, Han S. COVID-19-related myocarditis in a 21-year-old female patient. Eur Heart J. 2020;41(19):1859.

6. Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5.

7. Doyen D, Moceri P, Ducreux D, Dellamonica J. Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Lancet. 2020;395(10235):1516.

8. Trogen B, Gonzalez FJ, Shust GF. COVID-19-associated myocarditis in an adolescent. Pediatr Infect Dis J. 2020;39(8):e204-5.

9. Sardari A, Tabarsi P, Borhany H, Mohiaddin R, Houshmand G. Myocarditis detected after COVID-19 recovery. Eur Heart J Cardiovasc Imaging. 2020;jeaa166.

10. Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6.

11. Beşler MS, Arslan H. Acute myocarditis associated with COVID-19 infection. Am J Emerg Med. 2020;S0735-6757(20)30463-0.

12. Yuan WF, Tang X, Zhao XX. An ‘asymptomatic’ driver with COVID-19: atypical suspected myocarditis by SARS-CoV-2. Cardiovasc Diagn Ther. 2020;10(2):242-3.

13. Cizgici AY, Zencirkiran Agus H, Yildiz M. COVID-19 myopericarditis: it should be kept in mind in today’s conditions. Am J Emerg Med. 2020;38(7):1547.e5-1547.e6.

14. Asif T, Ali Z. Transient ST segment elevation in two patients with COVID-19 and a normal transthoracic echocardiogram. Eur J Case Rep Intern Med. 2020;7(5):001672.

15. Juusela A, Nazir M, Gimovsky M. Two cases of coronavirus 2019-related cardiomyopathy in pregnancy. Am J Obstet Gynecol MFM. 2020;2(2):100113.

16. Pavon AG, Meier D, Samim D, Rotzinger DC, Fournier S, Marquis P, et al. First documentation of persistent SARS-CoV-2 ınfection presenting with late acute severe myocarditis. Can J Cardiol. 2020;S0828-282X(20)30532-8.
- 1717. Irabien-Ortiz A, Carreras-Mora J, Sionis A, Pàmies J, Montiel J, Tauron M. Fulminant myocarditis due to COVID-19. Rev Esp Cardiol (Engl Ed). 2020;73(6):503-4. . The majority of the cases were male, and hypertension is the most commonly observed risk factor. In all patients, chest pain and dyspnea were the most common symptoms even though one case presented with atypical symptoms such as neck pain and diarrhea44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6.

5. Kim IC, Kim JY, Kim HA, Han S. COVID-19-related myocarditis in a 21-year-old female patient. Eur Heart J. 2020;41(19):1859.

6. Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5.

7. Doyen D, Moceri P, Ducreux D, Dellamonica J. Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Lancet. 2020;395(10235):1516.
- 88. Trogen B, Gonzalez FJ, Shust GF. COVID-19-associated myocarditis in an adolescent. Pediatr Infect Dis J. 2020;39(8):e204-5. . Fever is the most commonly observed sign in COVID-19 patients with acute myocarditis. Patients with lower systolic blood pressure developed cardiogenic shock following admission44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6. .

TABLE 1
BASELINE CHARACTERISTICS OF ALL COVID-19 ACUTE MYOCARDITIS PATIENTS
TABLE 2
IMAGING FINDINGS, IN-HOSPITAL TREATMENT, AND COURSE OF ALL COVID-19 ACUTE MYOCARDITIS PATIENTS

Lab findings

It is recommended to screen for cardiac injury in patients hospitalized for COVID-19 infection because an early diagnosis has an ultimate role in changing management. Therefore, the measurement of cardiac biomarkers, including troponin and brain natriuretic peptide (BNP), should be performed on admission. We noted that most cases had elevated troponin and BNP levels on admission. Lymphopenia was present in patients with COVID-19-related acute myocarditis, as expected in a usual viral infection.

Imaging features

In patients who are suspected of having COVID-19-related acute myocarditis, baseline electrocardiography (ECG) should be carried out on admission. In this review, we observed that ECG findings in most of the COVID-19 patients were non-specific, including diffuse ST-segment elevation, non-specific intraventricular conduction delay, sinus tachycardia, and inverted T-waves in anterior leads44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6.

5. Kim IC, Kim JY, Kim HA, Han S. COVID-19-related myocarditis in a 21-year-old female patient. Eur Heart J. 2020;41(19):1859.

6. Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5.

7. Doyen D, Moceri P, Ducreux D, Dellamonica J. Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Lancet. 2020;395(10235):1516.
- 88. Trogen B, Gonzalez FJ, Shust GF. COVID-19-associated myocarditis in an adolescent. Pediatr Infect Dis J. 2020;39(8):e204-5. , 1010. Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6. , 1414. Asif T, Ali Z. Transient ST segment elevation in two patients with COVID-19 and a normal transthoracic echocardiogram. Eur J Case Rep Intern Med. 2020;7(5):001672. , 1717. Irabien-Ortiz A, Carreras-Mora J, Sionis A, Pàmies J, Montiel J, Tauron M. Fulminant myocarditis due to COVID-19. Rev Esp Cardiol (Engl Ed). 2020;73(6):503-4. . Despite frequent changes in ECG, no specific changes were detected in some cases99. Sardari A, Tabarsi P, Borhany H, Mohiaddin R, Houshmand G. Myocarditis detected after COVID-19 recovery. Eur Heart J Cardiovasc Imaging. 2020;jeaa166. , 1616. Pavon AG, Meier D, Samim D, Rotzinger DC, Fournier S, Marquis P, et al. First documentation of persistent SARS-CoV-2 ınfection presenting with late acute severe myocarditis. Can J Cardiol. 2020;S0828-282X(20)30532-8. . Because there is the possibility of using a point-of-care ultrasound, it is recommended that echocardiography (ECHO) should be performed if there is a suspicion of COVID-19-related acute myocarditis. In this case-based review, the ECHO findings of patients with COVID-19-induced acute myocarditis ranged from preserved left ventricular ejection fraction (LVEF) without segmental abnormalities to reduced LVEF with global hypokinesia44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6. , 1010. Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6. , 1414. Asif T, Ali Z. Transient ST segment elevation in two patients with COVID-19 and a normal transthoracic echocardiogram. Eur J Case Rep Intern Med. 2020;7(5):001672.

15. Juusela A, Nazir M, Gimovsky M. Two cases of coronavirus 2019-related cardiomyopathy in pregnancy. Am J Obstet Gynecol MFM. 2020;2(2):100113.

16. Pavon AG, Meier D, Samim D, Rotzinger DC, Fournier S, Marquis P, et al. First documentation of persistent SARS-CoV-2 ınfection presenting with late acute severe myocarditis. Can J Cardiol. 2020;S0828-282X(20)30532-8.
- 1717. Irabien-Ortiz A, Carreras-Mora J, Sionis A, Pàmies J, Montiel J, Tauron M. Fulminant myocarditis due to COVID-19. Rev Esp Cardiol (Engl Ed). 2020;73(6):503-4. . Those with a severe and depressed LV function developed cardiogenic shock, thereby having a worse prognosis44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6. , 66. Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5. . Although CMR was not performed in all cases because of prolonged acquisition time and the fact that COVID-19 infection is highly contagious, it showed myocardial edema and sub-epicardial late gadolinium enhancement in some parts of the LV77. Doyen D, Moceri P, Ducreux D, Dellamonica J. Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Lancet. 2020;395(10235):1516.

8. Trogen B, Gonzalez FJ, Shust GF. COVID-19-associated myocarditis in an adolescent. Pediatr Infect Dis J. 2020;39(8):e204-5.

9. Sardari A, Tabarsi P, Borhany H, Mohiaddin R, Houshmand G. Myocarditis detected after COVID-19 recovery. Eur Heart J Cardiovasc Imaging. 2020;jeaa166.

10. Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6.

11. Beşler MS, Arslan H. Acute myocarditis associated with COVID-19 infection. Am J Emerg Med. 2020;S0735-6757(20)30463-0.
- 1212. Yuan WF, Tang X, Zhao XX. An ‘asymptomatic’ driver with COVID-19: atypical suspected myocarditis by SARS-CoV-2. Cardiovasc Diagn Ther. 2020;10(2):242-3. , 1616. Pavon AG, Meier D, Samim D, Rotzinger DC, Fournier S, Marquis P, et al. First documentation of persistent SARS-CoV-2 ınfection presenting with late acute severe myocarditis. Can J Cardiol. 2020;S0828-282X(20)30532-8. . Interestingly, no EMB was performed to confirm the diagnosis in all patients even though it is considered a gold standard. Hemodynamic instability, a contagious risk due to prolonged acquisition time, and coagulopathy were the main reasons for not performing EMB.

In-hospital treatment

There is no consensus for the prescription of the standard heart failure treatment in addition to the antiviral therapy to patients hospitalized with COVID-19-induced acute fulminant myocarditis. Interestingly, intravenous (IV) inotrope treatment and circulatory support have been used in selected cases. Moreover, IV glucocorticoid and immunoglobulin therapy have been implemented in patients with complicated acute myocarditis44. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6. , 66. Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5. , 1010. Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6. , 1515. Juusela A, Nazir M, Gimovsky M. Two cases of coronavirus 2019-related cardiomyopathy in pregnancy. Am J Obstet Gynecol MFM. 2020;2(2):100113. , 1717. Irabien-Ortiz A, Carreras-Mora J, Sionis A, Pàmies J, Montiel J, Tauron M. Fulminant myocarditis due to COVID-19. Rev Esp Cardiol (Engl Ed). 2020;73(6):503-4. . Most patients received heart failure therapy, antiviral, and antibiotic treatment according to the current literature. A few patients with COVID-19-induced acute fulminant myocarditis showed an amelioration using IV glucocorticoid and immunoglobulin therapy. This finding appears as a clue highlighting the cytokine storm due to inadequate host immune response, which might be the main pathophysiology of COVID-19-induced acute fulminant myocarditis.

Limitations in the diagnosis of COVID-19-related acute myocarditis

Acute viral infections are one of the most common etiologic factors of acute myocarditis. Following the COVID-19 pandemic, several cases of acute myocarditis were reported worldwide, which were diagnosed with different modalities other than EMB. In our review, all of the published cases were mentioned in terms of clinical characteristics, imaging findings, and in-hospital course.

Troponin has been indicated as an independent predictor of mortality in hospitalized patients with COVID-191818. Nie SF, Yu M, Xie T, Yang F, Wang HB, Wang ZH, et al. Cardiac troponin I is an ındependent predictor for mortality in hospitalized patients with coronavirus disease 2019. Circulation. 2020. doi: 10.1161/CIRCULATIONAHA.120.048789. , 1919. Imazio M, Klingel K, Kindermann I, Brucato A, De Rosa FG, Adler Y, et al. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis? Heart. 2020;heartjnl-2020-317186. doi: 10.1136/heartjnl-2020-317186. . Since troponin has been defined as a noteworthy prognostic factor, the etiology of the higher levels of troponin gains clinical importance to regulate adequate medications. In COVID-19 patients who present with elevated troponin levels, it might be difficult to reach a definitive diagnosis of acute coronary syndrome (ACS) or acute myocarditis because there are similarities among them in regard to the elevation of troponin levels and ECG changes. It is reasonable not to perform CMR and MRI in most patients due to the contiguousness of COVID-19. On the other hand, underusing the aforementioned modalities in the differential diagnosis reveals a gap in the definite etiology of the myocardial injury. Thus, we may be underestimating the prevalence and importance of COVID-19-related acute myocarditis. Moreover, in severe patients, both ACS and acute myocarditis may present together because of the procoagulant and inflammatory nature of the COVID-19 infection.

CONCLUSION

Despite the COVID-19 pandemic worldwide, a limited number of cases has been shared in the current literature. There are a lot of difficulties for the differential diagnosis of acute myocarditis in the context of COVID-19, and information about COVID-19-related acute myocarditis remains unclear. Also, there is no consensus about the diagnostic and treatment algorithms in patients with COVID-19-induced acute myocarditis. Hence, further studies and case reports on COVID-19-associated acute myocarditis are needed to clarify an appropriate approach to these patients.

REFERENCES

  • 1
    Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.
  • 2
    Bavishi C, Bonow RO, Trivedi V, Abbott JD, Messerli FH, Bhatt DL. Acute myocardial injury in patients hospitalized with COVID-19 infection: a review. Prog Cardiovasc Dis. 2020;S0033-0620(20)30123-7.
  • 3
    Lang JP, Wang X, Moura FA, Siddiqi HK, Morrow DA, Bohula EA. A current review of COVID-19 for the cardiovascular specialist. Am Heart J. 2020;226:29-44.
  • 4
    Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac ınvolvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1-6.
  • 5
    Kim IC, Kim JY, Kim HA, Han S. COVID-19-related myocarditis in a 21-year-old female patient. Eur Heart J. 2020;41(19):1859.
  • 6
    Zeng JH, Liu YX, Yuan J, Wang FX, Wu WB, Li JX, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. 2020;1-5.
  • 7
    Doyen D, Moceri P, Ducreux D, Dellamonica J. Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Lancet. 2020;395(10235):1516.
  • 8
    Trogen B, Gonzalez FJ, Shust GF. COVID-19-associated myocarditis in an adolescent. Pediatr Infect Dis J. 2020;39(8):e204-5.
  • 9
    Sardari A, Tabarsi P, Borhany H, Mohiaddin R, Houshmand G. Myocarditis detected after COVID-19 recovery. Eur Heart J Cardiovasc Imaging. 2020;jeaa166.
  • 10
    Coyle J, Igbinomwanhia E, Sanchez-Nadales A, Danciu S, Chu C, Shah N. A recovered case of COVID-19 myocarditis and ARDS treated with corticosteroids, tocilizumab, and experimental AT-001. JACC Case Rep. 2020;2(9):1331-6.
  • 11
    Beşler MS, Arslan H. Acute myocarditis associated with COVID-19 infection. Am J Emerg Med. 2020;S0735-6757(20)30463-0.
  • 12
    Yuan WF, Tang X, Zhao XX. An ‘asymptomatic’ driver with COVID-19: atypical suspected myocarditis by SARS-CoV-2. Cardiovasc Diagn Ther. 2020;10(2):242-3.
  • 13
    Cizgici AY, Zencirkiran Agus H, Yildiz M. COVID-19 myopericarditis: it should be kept in mind in today’s conditions. Am J Emerg Med. 2020;38(7):1547.e5-1547.e6.
  • 14
    Asif T, Ali Z. Transient ST segment elevation in two patients with COVID-19 and a normal transthoracic echocardiogram. Eur J Case Rep Intern Med. 2020;7(5):001672.
  • 15
    Juusela A, Nazir M, Gimovsky M. Two cases of coronavirus 2019-related cardiomyopathy in pregnancy. Am J Obstet Gynecol MFM. 2020;2(2):100113.
  • 16
    Pavon AG, Meier D, Samim D, Rotzinger DC, Fournier S, Marquis P, et al. First documentation of persistent SARS-CoV-2 ınfection presenting with late acute severe myocarditis. Can J Cardiol. 2020;S0828-282X(20)30532-8.
  • 17
    Irabien-Ortiz A, Carreras-Mora J, Sionis A, Pàmies J, Montiel J, Tauron M. Fulminant myocarditis due to COVID-19. Rev Esp Cardiol (Engl Ed). 2020;73(6):503-4.
  • 18
    Nie SF, Yu M, Xie T, Yang F, Wang HB, Wang ZH, et al. Cardiac troponin I is an ındependent predictor for mortality in hospitalized patients with coronavirus disease 2019. Circulation. 2020. doi: 10.1161/CIRCULATIONAHA.120.048789.
  • 19
    Imazio M, Klingel K, Kindermann I, Brucato A, De Rosa FG, Adler Y, et al. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis? Heart. 2020;heartjnl-2020-317186. doi: 10.1136/heartjnl-2020-317186.
  • Funding
    The authors declare that this article has received no financial support.

Publication Dates

  • Publication in this collection
    21 Sept 2020
  • Date of issue
    2020

History

  • Received
    23 June 2020
  • Accepted
    11 July 2020
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