Division of Cardiology, Department of Medicine (N.L.A., R.A.Q., E.A.G., M.R.B.), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora.
Department of Pathology (A.A.B.), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora.
Circ Res. 2023 May 12;132(10):1338-1357. doi: 10.1161/CIRCRESAHA.122.321881. Epub 2023 May 11.
SARS-CoV-2 vaccine-associated myocarditis/myocardial injury should be evaluated in the contexts of COVID-19 infection, other types of viral myocarditis, and other vaccine-associated cardiac disorders. COVID-19 vaccine-associated myocardial injury can be caused by an inflammatory immune cell infiltrate, but other etiologies such as microvascular thrombosis are also possible. The clinical diagnosis is typically based on symptoms and cardiac magnetic resonance imaging. Endomyocardial biopsy is confirmatory for myocarditis, but may not show an inflammatory infiltrate because of rapid resolution or a non-inflammatory etiology. Myocarditis associated with SARS-COVID-19 vaccines occurs primarily with mRNA platform vaccines, which are also the most effective. In persons aged >16 or >12 years the myocarditis estimated crude incidences after the first 2 doses of BNT162b2 and mRNA-1273 are approximately 1.9 and 3.5 per 100 000 individuals, respectively. These rates equate to excess incidences above control populations of approximately 1.2 (BNT162b2) and 1.9 (mRNA-1273) per 100 000 persons, which are lower than the myocarditis rate for smallpox but higher than that for influenza vaccines. In the studies that have included mRNA vaccine and SARS-COVID-19 myocarditis measured by the same methodology, the incidence rate was increased by 3.5-fold over control in COVID-19 compared with 1.5-fold for BNT162b2 and 6.2-fold for mRNA-1273. However, mortality and major morbidity are less and recovery is faster with mRNA vaccine-associated myocarditis compared to COVID-19 infection. The reasons for this include vaccine-associated myocarditis having a higher incidence in young adults and adolescents, typically no involvement of other organs in vaccine-associated myocarditis, and based on comparisons to non-COVID viral myocarditis an inherently more benign clinical course.
SARS-CoV-2 疫苗相关心肌炎/心肌损伤应结合 COVID-19 感染、其他类型的病毒性心肌炎和其他疫苗相关心脏疾病进行评估。COVID-19 疫苗相关心肌损伤可能由炎症免疫细胞浸润引起，但也可能存在其他病因，如微血管血栓形成。临床诊断通常基于症状和心脏磁共振成像。心肌活检可明确心肌炎的诊断，但由于快速消退或非炎症性病因，可能不会显示炎症浸润。与 SARS-COVID-19 疫苗相关的心肌炎主要发生在 mRNA 平台疫苗接种后，而这些疫苗也是最有效的。在年龄 >16 岁或 >12 岁的人群中，接种 2 剂 BNT162b2 和 mRNA-1273 后，估计心肌炎的粗发病率分别约为每 10 万人 1.9 和 3.5 例。这些发病率相当于对照人群中每 10 万人的超额发病率约为 1.2（BNT162b2）和 1.9（mRNA-1273），低于天花疫苗，但高于流感疫苗。在纳入相同方法学测量 mRNA 疫苗和 SARS-COVID-19 心肌炎的研究中，与 BNT162b2 相比，COVID-19 中的发病率增加了 3.5 倍，而 mRNA-1273 则增加了 6.2 倍。然而，与 COVID-19 感染相比，mRNA 疫苗相关心肌炎的死亡率和主要发病率较低，恢复较快。其原因包括疫苗相关心肌炎在年轻成人和青少年中的发病率较高，疫苗相关心肌炎通常不涉及其他器官，并且与非 COVID 病毒心肌炎相比，其临床过程具有内在的良性。
