Comparison of MIS-C Related Myocarditis, Classic Viral Myocarditis, and COVID-19 Vaccine related Myocarditis in Children
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Abstract
Background
Although rare, myocarditis in the pediatric population is a disease process that carries significant morbidity and mortality. Prior to the SARS-CoV-2 related (COVID-19) pandemic, enteroviruses were the most common cause of classic myocarditis. However, since 2020, myocarditis linked to multisystem inflammatory syndrome in children (MIS-C) is now common. In recent months, myocarditis related to COVID-19 vaccines has also been described. This study aims to compare these three different types of myocarditis with regards to clinical presentation, course, and outcomes.
Methods
In this retrospective cohort study, we included all patients <21 years of age hospitalized at our institution with classic viral myocarditis from 2015-2019, MIS-C myocarditis from 3/2020-2/2021 and COVID-19 vaccine-related myocarditis from 5/2021-6/2021. We compared demographics, initial symptomatology, treatment, laboratory data, and echocardiogram findings.
Results
Of 201 total participants, 43 patients had classic myocarditis, 149 had MIS-C myocarditis, and 9 had COVID-19 vaccine-related myocarditis. Peak troponin was highest in the classic myocarditis group, whereas the MIS-C myocarditis group had the highest recorded brain natriuretic peptide (BNP). There were significant differences in time to recovery of normal left ventricular ejection fraction (LVEF) for the three groups: nearly all patients with MIS-C myocarditis (n=139, 93%) and all patients with COVID-19 vaccine-related myocarditis (n=9, 100%) had normal LVEF at the time of discharge, but a lower proportion of the classic myocarditis group (n=30, 70%) had a normal LVEF at discharge (p<0.001). Three months post-discharge, 18 of 40 children (45%) in the classic myocarditis group still required heart failure treatment, whereas only one of the MIS-C myocarditis patients and none of the COVID-19 vaccine-associated myocarditis patients did.
Conclusions
Compared to those with classic myocarditis, those with MIS-C myocarditis had more significant hematologic derangements and worse inflammation at presentation, but had better clinical outcomes, including rapid recovery of cardiac function. Patients with COVID-19 vaccine-related myocarditis had similar clinical presentation to patients with classic myocarditis, but their pattern of recovery was similar to those with MIS-C, with prompt resolution of symptoms and improvement of cardiac function. Long-term follow-up should focus on cardiac and non-cardiac consequences of myocarditis associated with COVID-19 illness and vaccination.
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Michael Campbell
Review 1: "Comparison of MIS-C Related Myocarditis, Classic Viral Myocarditis, and COVID-19 Vaccine related Myocarditis in Children"
Reviewer: Michael Campbell (Duke University) | 📗📗📗📗◻️
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Michael Campbell
Review of "Comparison of MIS-C Related Myocarditis, Classic Viral Myocarditis, and COVID-19 Vaccine related Myocarditis in Children"
Reviewer: Michael Campbell (Duke University) | 📗📗📗📗◻️
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SciScore for 10.1101/2021.10.05.21264581: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: The study was approved by the Institutional Review Board of Children’s Healthcare of Atlanta. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources Statistical Analysis: Statistical analyses were performed using SAS v9.4 (SAS Institute, Cary, NC) and statistical significance was assessed at the 0.05 level. SAS Institutesuggested: (Statistical Analysis System, RRID:SCR_008567)Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: …SciScore for 10.1101/2021.10.05.21264581: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: The study was approved by the Institutional Review Board of Children’s Healthcare of Atlanta. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources Statistical Analysis: Statistical analyses were performed using SAS v9.4 (SAS Institute, Cary, NC) and statistical significance was assessed at the 0.05 level. SAS Institutesuggested: (Statistical Analysis System, RRID:SCR_008567)Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Limitations: There are important limitations in our study. Our data reflect patients hospitalized at a single tertiary pediatric institution. Thus, it represents our center’s approach to classic myocarditis, MIS-C myocarditis, and vaccine-related myocarditis and may not be generalizable to all children with myocarditis. By including only hospitalized patients, we also may have missed patients with subclinical findings, in whom the clinical course may have been different. Additionally, we did not have cardiac MRI data for comparisons between the groups. Given the concerns for active infection and potential hemodynamic instability, patients with MIS-C myocarditis did not undergo cardiac MRI at the time of presentation. Cardiac MRI (cMRI) is the gold standard for non-invasive diagnosis of myocarditis and thus, even in the setting of elevated troponin and symptoms, some patients with MIS-C myocarditis included in this study may not have met cMRI criteria for diagnosis of myocarditis. 5 The inclusion of patients with signs of mild myocardial inflammation but not true myocarditis based on cMRI may therefore have overrepresented the number of patients who had full cardiac recovery. The patients with vaccine-related myocarditis did undergo cardiac MRI during their initial hospitalization, but most have not yet undergone follow-up MRI testing. This testing will be important to assess for evidence of ongoing myocardial inflammation and risk for sequelae other than decreased function. F...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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