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Heart, Lung and Circulation

Reply to Letter to the Editor Regarding: “Myocarditis and Cardiac Complications Associated With COVID-19 and mRNA Vaccination”

Published:August 03, 2022DOI:https://doi.org/10.1016/j.hlc.2022.07.002

      Keywords

      To the Editor,
      We thank Lampejo and Durkin for their interest in our recent publication, Myocarditis and Cardiac Complications Associated With COVID-19 and mRNA Vaccination: A Pragmatic Narrative Review to Guide Clinical Practice [
      • Holland D.J.
      • Blazak P.L.
      • Martin J.
      • Broom J.
      • Poulter R.S.
      • Stanton T.
      Myocarditis and cardiac complications associated with COVID-19 and mRNA vaccination: a pragmatic narrative review to guide clinical practice.
      ], and for their letter regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs) in these clinical settings.
      The management of COVID-19 and the complications of specific organ involvement is a rapidly expanding area of medicine, and there are limited data on the treatment of COVID-19 and mRNA vaccination-related myocarditis. In general, the use of NSAIDs in myocarditis is not recommended [
      • Caforio A.L.
      • Pankuweit S.
      • Arbustini E.
      • Basso C.
      • Gimeno-Blanes J.
      • Felix S.B.
      • et al.
      Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
      ], based on experimental data from seminal animal studies indicating possible harm in viral aetiologies of myocarditis. Furthermore, NSAIDs are generally discouraged in acute or chronic cases of heart failure [
      • Atherton J.J.
      • Sindone A.
      • De Pasquale C.G.
      • Driscoll A.
      • MacDonald P.S.
      • Hopper I.
      • et al.
      National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018.
      ]. Though widely used in cases of isolated pericarditis, human safety data of NSAIDs in myocarditis and myopericarditis is limited to small retrospective audits [
      • Mirna M.
      • Schmutzler L.
      • Topf A.
      • Boxhammer E.
      • Sipos B.
      • Hoppe U.C.
      • et al.
      Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) does not affect outcome in patients with acute myocarditis or myopericarditis.
      ,
      • Berg J.
      • Lovrinovic M.
      • Baltensperger N.
      • Kissel C.K.
      • Kottwitz J.
      • Manka R.
      • et al.
      Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up.
      ], and robust data related specifically to COVID-19 is absent. Importantly, NSAIDs remain first-line therapy in pericarditis [
      • Adler Y.
      • Charron P.
      • Imazio M.
      • Badano L.
      • Barón-Esquivias G.
      • Bogaert J.
      • et al.
      2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).
      ]. However, we agree with Lampejo and Durkin that, consistent with guideline recommendations for myocarditis and pericarditis [
      • Caforio A.L.
      • Pankuweit S.
      • Arbustini E.
      • Basso C.
      • Gimeno-Blanes J.
      • Felix S.B.
      • et al.
      Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
      ,
      • Adler Y.
      • Charron P.
      • Imazio M.
      • Badano L.
      • Barón-Esquivias G.
      • Bogaert J.
      • et al.
      2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).
      ], the use of NSAIDs should be carefully considered in cases related to COVID-19 or presentation associated with mRNA vaccination.

      References

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        • Blazak P.L.
        • Martin J.
        • Broom J.
        • Poulter R.S.
        • Stanton T.
        Myocarditis and cardiac complications associated with COVID-19 and mRNA vaccination: a pragmatic narrative review to guide clinical practice.
        Heart Lung Circ. 2022; 31: 924-933
        • Caforio A.L.
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        • Basso C.
        • Gimeno-Blanes J.
        • Felix S.B.
        • et al.
        Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
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        • Atherton J.J.
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        • Hopper I.
        • et al.
        National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018.
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        • Mirna M.
        • Schmutzler L.
        • Topf A.
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        • Sipos B.
        • Hoppe U.C.
        • et al.
        Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) does not affect outcome in patients with acute myocarditis or myopericarditis.
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        • Berg J.
        • Lovrinovic M.
        • Baltensperger N.
        • Kissel C.K.
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        Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up.
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        • Adler Y.
        • Charron P.
        • Imazio M.
        • Badano L.
        • Barón-Esquivias G.
        • Bogaert J.
        • et al.
        2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2015; 36: 2921-2964

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