Abstract
Purpose
The number of patients presenting with vaccination-related cardiovascular symptoms after receiving mRNA vaccines (mRNA-VRCS) is increasing. We investigated the incidence of vaccine-related adverse events (VAEs), including myocarditis and pericarditis, in patients with mRNA-VRCS after receiving BNT162b2-Pfizer-BioNTech and mRNA-1273-Moderna vaccines.
Materials and Methods
We retrospectively collected data on patients presenting with mRNA-VRCS who visited the outpatient clinic of two tertiary medical centers. Clinical characteristics, laboratory findings, echocardiographic findings, and electrocardiographic findings were evaluated. VAE was defined as myocarditis or pericarditis in patients after mRNA vaccination. Clinical outcomes during short-term follow-up, including emergency room (ER) visit, hospitalization, or death, were also assessed among the patients.
Results
A total of 952 patients presenting with mRNA-VRCS were included in this study, with 89.7% receiving Pfizer-BioNTech and 10.3% receiving Moderna vaccines. The mean duration from vaccination to symptom was 5.6±7.5 days. VAEs, including acute myocarditis and acute pericarditis, were confirmed in 11 (1.2%) and 10 (1.1%) patients, respectively. The VAE group showed higher rates of dyspnea, echocardiography changes, and ST-T segment changes. During the short-term follow-up period of 3 months, the VAE group showed a higher hospitalization rate compared to the control group; there was no significant difference in ER visit (p=0.320) or mortality rates (p>0.999).
Conclusion
Amongst the patients who experienced mRNA-VRCS, the total incidence of VAEs, including acute myocarditis and pericarditis, was 2.2%. Patients with VAEs showed higher rates of dyspnea, echocardiographic changes, and ST-T segment changes compared to those without VAEs. With or without the cardiovascular events, the prognosis in patients with mRNA-VRCS was favorable.
Keywords: COVID-19, mRNA vaccine, myocarditis, pericarditis
Graphical Abstract
INTRODUCTION
Following the pandemic of coronavirus disease 2019 (COVID-19), there have been growing worldwide reports on the incidence of myocarditis and/or pericarditis within 1–2 weeks after receiving messenger RNA (mRNA) COVID-19 vaccines, including Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273.1,2 While myocarditis is known to be associated with smallpox and influenza vaccines,3,4 rare cases of myocarditis have been reported in adults after mRNA vaccination in Israel5 and the U.S. military.2
Common features of these post-COVID-19 vaccine reports of myocarditis are the very low incidence (1.6 per million doses for mRNA vaccines)6,7 and general similarity of patient demographics, condition, symptom onset, and outcomes.2,8,9,10 However, the reported adverse events following COVID-19 vaccination have been of major concern to the public, particularly when associated with the death of “previously healthy” individuals.
In Korea, mRNA COVID-19 vaccination was approved and initiated in February 2021. The number of patients complaining of cardiovascular symptoms after receiving mRNA vaccines showed a short but significant increase subsequently. Many of the patients were concerned that their symptoms were similar to those of myocarditis or pericarditis, which are serious side effects of vaccination. These patients already had these typical cardiovascular symptoms after vaccination and were frequently encountered by cardiologists in the clinical field.
Therefore, we investigated the incidence, clinical characteristics, and outcomes of adverse events in patients with vaccination-related cardiovascular symptoms after receiving mRNA vaccines (mRNA-VRCS) using real-world data.
MATERIALS AND METHODS
Study population and clinical characteristics
This retrospective observational study was based on medical records from two medical centers [Severance Cardiovascular Hospital (n=404) and Ilsan Paik Hospital (n=548)] in Korea. Between April 2021 and December 2021, we retrieved and collected data of patients presenting to the outpatient clinic with typical cardiovascular symptoms among those who had received mRNA coronavirus disease 2019 vaccines (BNT162b2-Pfizer-BioNTech or mRNA-1273-Moderna). Cardiovascular symptoms included chest pain, dyspnea, and palpitation. We reviewed the medical records of each patient, including the demographic, clinical, echocardiographic, electrocardiographic (ECG), and laboratory findings (Fig. 1).
Fig. 1. Study population and flow chart.
For all enrolled patients, the data were carefully reviewed by a single cardiologist at the respective medical centers. The study protocol was approved by the Institutional Review Board of Ilsan Paik Hospital (IRB No. 2021-11-025) and Severance Hospital (IRB No. 4-2022-0439), and the need for informed consent was waived.
Definition of adverse cardiovascular events after mRNA vaccination
In this study, vaccine-related adverse events (VAEs) were defined as myocarditis and pericarditis. We identified patients with clinically suspected myocarditis who had elevated troponin levels, abnormal ECG findings, cardiac function on non-invasive imaging such as echocardiography, or findings consistent with myocarditis on cardiac magnetic resonance imaging.11 Cases of suspected VAEs were defined according to the Centers for Disease Control and Prevention (CDC) work case definitions of probable myocarditis, confirmed myocarditis, and acute pericarditis.1,12 In addition, as adverse events were confirmed while reviewing the data, we investigated 3-month short-term outcomes, including emergency room (ER) visit, hospitalization, and death.
Statistical analysis
Continuous variables were compared using Student’s t-test or Wilcoxon rank-sum test where applicable, and are presented as mean±standard deviation or median with interquartile range (IQR). Categorical data were analyzed using Fisher’s exact test or the chi-square test as appropriate between the groups with and without adverse cardiovascular events after mRNA vaccination. Statistical significance was set at p<0.05. All analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA).
RESULTS
Demographic, clinical data, and vaccination data
The baseline demographic and clinical characteristics of the patients are shown in Table 1. A total of 949 patients with cardiovascular symptoms after mRNA vaccination were included in this study. The study population included 431 male patient (45.3%), and the mean age of all patients was 37.1±14.1 years. The most common baseline comorbidities included dyslipidemia (7.1%), hypertension (6.1%), and diabetes mellitus (2.1%). The onset of symptoms occurred at 5.6±7.5 days after vaccine administration. Of all patients, 853 (89.7%) had received the Pfizer-BioNTech vaccine, of whom 529 (55.6%) developed symptoms at the first dose and 283 (29.9%) at the second dose. Additionally, 98 (10.3%) patients had received the Moderna vaccine, of whom 67 (7.0%) developed symptoms at the first dose and 26 (2.7%) at the second dose.
Table 1. Baseline Characteristics (n=949).
| Parameters | Value | ||
|---|---|---|---|
| Age (yr) | 37.1±14.1 | ||
| Sex, male | 431 (45.3) | ||
| Baseline comorbidities | |||
| Hypertension | 58 (6.1) | ||
| Heart failure | 12 (1.3) | ||
| Coronary artery disease | 13 (1.4) | ||
| Congenital heart disease | 2 (0.2) | ||
| Atrial fibrillation | 6 (0.6) | ||
| Myocarditis | 1 (0.1) | ||
| Diabetes mellitus | 20 (2.1) | ||
| Bronchial asthma | 5 (0.5) | ||
| COPD | 1 (0.1) | ||
| Dyslipidemia | 68 (7.1) | ||
| Chronic kidney disease | 4 (0.4) | ||
| Hyperthyroidism | 3 (0.3) | ||
| Hypothyroidism | 3 (0.3) | ||
| Anxiety | 5 (0.5) | ||
| HIV infection | 1 (0.1) | ||
| Duration from vaccination to symptom (day) | 5.6±7.5 | ||
| Vaccination type | |||
| Pfizer-BioNTech | 853 (89.7) | ||
| First | 529 (55.6) | ||
| Second | 283 (29.9) | ||
| Moderna | 98 (10.3) | ||
| First | 67 (7.0) | ||
| Second | 26 (2.7) | ||
COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus.
Categorical variables are presented as the number of patients (%), and continuous variables as mean±standard deviation.
Post-vaccination symptoms are presented in Table 2. Among the mRNA-VRCS, chest pain was the most common symptom, occurring in 763 (80.1%) patients at various locations including sternal (38.8%), left chest (16.5%), and substernal (2.6%). Dyspnea and palpitation each occurred in 383 (40.2%) and 271 patients (28.5%), respectively.
Table 2. Vaccine-Related Cardiac Symptoms after mRNA Vaccination (n=949).
| Parameters | Value | |
|---|---|---|
| Chest pain | 763 (80.1) | |
| Sternal | 368 (38.8) | |
| Substernal | 25 (2.6) | |
| Left chest | 157 (16.5) | |
| Right chest | 18 (1.9) | |
| Epigastric | 7 (0.7) | |
| Whole chest | 24 (2.5) | |
| Dyspnea | 383 (40.2) | |
| Palpitation | 271 (28.5) | |
Data are presented as n (%).
Echocardiographic data
Among the enrolled patients with cardiovascular symptoms, 502 (52.7%) patients underwent echocardiography (Supplementary Table 1, only online). The median value of ejection fraction for evaluating left ventricular systolic function was 66.0±5.9%, and only five patients had ejection fractions below 50%. The mean value of global longitudinal strain (145 patients estimated) was -18.1±4.2%. The number of patients with pericardial effusion was 13 (2.6%), and all were less than small amount of pericardial effusion. Only two patients had constrictive physiology, and eight patients had abnormal wall motion changes.
ECG data and additional cardiac evaluation
ECG findings are presented in Supplementary Table 1 (only online), and 838 (88.0%) patients were normal. ST-T segment change was found in 4.5% of the total patients: non-specific ST-T segment change in 44.2%, early repolarization in 20.9%, and T wave abnormality in 7.0%. Other common ECG changes (81 patients, 8.5%) included sinus bradycardia (22.2%), ventricular premature beats (22.2%), and right bundle branch block or left anterior and posterior fascicular block (21.0%).
Among other cardiac evaluations, coronary computed tomography angiography was performed in 3.3%, treadmill test in 1.7%, invasive coronary angiography in 0.5%, and triple computed tomography in 0.3%.
Laboratory data
Laboratory test results are shown in Table 3. Among the cardiac markers, troponin I (82.2%) and creatine kinase-MB (78.0%) were tested in most patients, while CK and N-terminal pro B-type natriuretic peptide were tested only in 30.1% and 30.3%, respectively. The median values of all cardiac markers were within the normal range. Other laboratory findings were also reviewed, and the number of patients who underwent tests ranged from 55.3% to 81.1%. The median values of all parameters were also within the normal range. White blood cell counts with differential (neutrophil and lymphocyte, %) for representing inflammation or infection were as follows: leukocyte [6395.0/µL, IQR (5210.0–7747.5)], neutrophils [56.9%, IQR (50.0–63.9)] and lymphocytes [32.6%, IQR (26.8–38.9)]. Additionally, laboratory findings related to systemic inflammatory reactions were reviewed; erythrocyte sedimentation rate [4.0 mm/hr, IQR (2.0–9.0)] in 549 patients, C-reactive protein [0.10 mg/dL, IQR (0.10–0.20)] in 615 patients, and D-dimer [0.270 µg/mL (fibrinogen equivalent unit-FEU), IQR (0.078–0.270)] in 526 patients.
Table 3. Laboratory Findings of the Study Population (n=949).
| Parameters | Patients who underwent tests (%) | Median (IQR) | |
|---|---|---|---|
| Cardiac laboratory findings | |||
| CK (U/L) | 30.1 | 82.0 (63.0–123.0) | |
| CK-MB (ng/mL) | 78.0 | 0.60 (0.40–1.00) | |
| Troponin I (pg/mL) | 82.2 | 1.90 (1.00–2.30) | |
| NT-proBNP (pg/mL) | 30.3 | 32.0 (15.65–74.25) | |
| D-dimer (μg/mL-FEU) | 55.3 | 0.270 (0.078–0.270) | |
| Hemoglobin (g/dL) | 81.1 | 13.90 (13.0–15.3) | |
| Platelet (K/μL) | 81.1 | 258.0 (219.0–297.8) | |
| Leukocyte (/μL) | 81.1 | 6395.0 (5210.0–7747.5) | |
| Neutrophil (%) | 78.9 | 56.9 (50.0–63.9) | |
| Lymphocyte (%) | 78.9 | 32.6 (26.8–38.9) | |
| ESR (mm/hr) | 57.7 | 4.0 (2.0–9.0) | |
| CRP (mg/dL) | 64.6 | 0.10 (0.10–0.20) | |
| BUN (mg/dL) | 79.5 | 12.0 (9.9–14.7) | |
| Creatinine (mg/dL) | 79.5 | 0.78 (0.66–0.91) | |
| GFR-MDRD (mL/min/1.73m2) | 79.5 | 101.0 (90.2–115.0) | |
| Sodium level (mEq/L) | 77.0 | 140.0 (139.0–141.0) | |
| Total bilirubin (mg/dL) | 77.0 | 0.60 (0.40–0.80) | |
| AST (U/L) | 77.8 | 20.0 (16.0–24.5) | |
| ALT (U/L) | 77.8 | 17.0 (11.0–27.5) | |
CK, creatine kinase; CK-MB, creatine kinase-MB; NT-proBNP, N-terminal pro B-type natriuretic peptide; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; BUN, blood urea nitrogen; GFR-MDRD, glomerular filtration rate–Modification of Diet in Renal Disease; AST, aspartate transaminase; ALT, alanine transaminase.
Comparison between the groups with and without adverse cardiovascular events
VAEs occurred in 21 out of 949 patients who had received mRNA vaccines at the two medical centers (Table 4 and Supplementary Table 2, only online). Based on symptoms, laboratory, and imaging data, nine patients were classified as having myocarditis, nine patients as having pericarditis, and three patients as having myopericarditis according to the CDC classification. The demographic and vaccination data were not significantly different between the two groups. There was also no significant difference in the onset of symptoms from vaccination between the groups. Among the symptoms, the VAE group showed a significantly higher percentage of dyspnea compared to the group without adverse events (71.4% vs. 39.5%, p=0.004). Regarding troponin-I, the median values in myocarditis and pericarditis patients were 4.75 (1.75–58.35) pg/mL and 2.00 (1.00–6.00) pg/mL, respectively.
Table 4. Comparison between Groups With and Without Vaccine-Related Adverse Events.
| With adverse events* (n=21) | Without adverse events (n=928) | p value | |||
|---|---|---|---|---|---|
| Age (yr) | 37.1±15.9 | 37.1±14.0 | >0.999 | ||
| Sex, male | 12 (57.1) | 419 (45.0) | 0.280 | ||
| Duration from vaccination to symptom (day) | 7.3±11.8 | 5.5±7.4 | 0.510 | ||
| Vaccination type | 0.720 | ||||
| Pfizer-BioNTech | 20 (95.2) | 833 (89.5) | |||
| First | 8 (38.1) | 521 (56.0) | |||
| Second | 12 (57.1) | 271 (29.1) | |||
| Moderna | 1 (4.8) | 97 (10.4) | |||
| First | 0 | 67 (7.2) | |||
| Second | 1 (4.8) | 25 (2.7) | |||
| Symptoms | |||||
| Chest pain | 20 (95.2) | 742 (79.7) | 0.100 | ||
| Dyspnea | 15 (71.4) | 368 (39.5) | 0.004 | ||
| Palpitation | 7 (33.3) | 264 (28.4) | 0.630 | ||
| Echocardiography findings | |||||
| Pericardial effusion | 5 (23.8) | 8 (0.9) | <0.001 | ||
| Constrictive physiology | 2 (9.5) | 0 | <0.001 | ||
| Wall motion abnormality | 3 (14.3) | 5 (0.5) | <0.001 | ||
| ECG findings | 20 (95.2) | 482 (51.9) | <0.050 | ||
| Normal ECG | 14 (66.7) | 820 (88.1) | 0.010 | ||
| ST-T segment change | 6 (28.6) | 38 (4.1) | 0.002 | ||
| Other ECG changes | 4 (21.0) | 77 (8.3) | 0.100 | ||
| Inflammatory biomarkers | |||||
| Neutrophil-to-lymphocyte ratio | 2.2 (1.6–2.6) | 1.8 (1.3–2.4) | 0.513 | ||
| CRP (mg/dL) | 0.26 (0.09–0.83) | 0.10 (0.09–0.20) | 0.112 | ||
ECG, electrocardiogram; CRP, C-reactive protein.
Data are presented as n (%), mean±standard deviation or median (Interquartile range).
*Vaccine-related adverse cardiovascular events, including myocarditis or pericarditis.
In the echocardiographic data, a higher proportion of patients with VAEs presented with pericardial effusion (23.8% vs. 0.9%, p<0.001), constrictive physiology (9.5% vs. 0.0%, p<0.001), and wall motion abnormality changes (14.3% vs. 0.5%, p<0.001). Abnormal ECG findings were also more common in the VAE group, as the percentage of ST-T segment changes were significantly higher (28.6% vs. 4.1%, p=0.002).
Short-term clinical outcomes
The defined clinical outcomes within a 3-month period from initial evaluation were assessed and compared between the two groups (Table 5). The hospitalization rate was significantly higher in the VAE group compared to the non-VAE group (28.6% vs. 1.3%, p<0.001). However, there was no significant difference in the percentage of ER visit (4.8% vs. 15.0%, p=0.320) and mortality (0% vs. 0.1%, p>0.999) between the two groups.
Table 5. Short-Term Clinical Outcomes.
| With adverse events* (n=21) | Without adverse events (n=928) | p value | |
|---|---|---|---|
| Emergency room visit | 1 (4.8) | 139 (15.0) | 0.320 |
| Hospitalization | 6 (28.6) | 14 (1.3) | <0.001 |
| Death | 0 (0.0) | 1 (0.1) | >0.999 |
Data are presented as n (%).
*Vaccine-related adverse cardiovascular events, including myocarditis or pericarditis.
DISCUSSION
This study evaluated real-world data on the incidence, clinical characteristics, and outcomes of adverse cardiovascular events, including myocarditis and pericarditis, in patients with cardiovascular symptoms following mRNA vaccination. Chest pain was the most common symptom, with the incidence of VAE being 2.2%. The VAE group had a significantly higher percentage of dyspnea, as well as abnormal echocardiographic and ECG findings, when compared to the control group. While there was a higher rate in hospitalization in the VAE group, other short-term clinical outcomes, including ER visit and mortality, showed no difference.
A recent nationwide study reported that myocarditis and pericarditis following mRNA vaccination are extremely rare.13 Especially being more frequent in males, adolescents, and young adults, the VAE rates were reported to be 12.6 cases per million doses of second-dose mRNA vaccine in the United States.14 Although there were more female patients with post-vaccination cardiovascular symptoms in our study, VAE was more common in male patients with myocarditis especially having a higher percentage of 63.6%. These findings were consistent with those of a previous study by Oh, et al.,15 where 62.4% of the patients with post-vaccination adverse reactions were female and all four patients diagnosed with myocarditis were male. The VAE rate of 2.2% was assessed among patients with cardiovascular symptoms, which can be presumed to be significantly lower when compared to the total vaccinated population. However, as substantial patients complained of cardiovascular symptoms after mRNA vaccination and presented to the outpatient clinic, the attending clinicians had difficulty in determining the occurrence of severe cardiovascular adverse events in these patients based on symptoms alone. In this study, chest pain (80.1%) was the most common mRNA-VRCS, followed by dyspnea (40.2%) and palpitation (28.5%). Previous studies also showed that the common chief complaints of patients visiting the ER after mRNA vaccination included chest pain/discomfort, dyspnea, and palpitation, with 0.6% being diagnosed with myocarditis.15,16,17 Therefore, further detailed examinations are recommended for the evaluation of those with mRNA-VRCS despite the rare incidence of myocarditis/pericarditis.14
The etiology of mRNA-VRCS is yet unclear, but in general, patients with normal cardiac evaluation results are more likely to have a systemic vaccine-induced inflammatory response. There is substantial variability in individuals’ immune responses to vaccines, and there is currently no routinely available method to objectively identify a specific person’s response to a vaccine beyond self-reported side effects, which are common.18 Most cases have self-limiting symptoms that require mild or no treatment. However, in cases of probable VAEs, including myocarditis and pericarditis, detailed cardiac evaluations should be performed. While the diagnosis is important, it is also vital that the etiology is carefully distinguished between vaccine-related myocarditis/pericarditis and other etiologies (complex co-morbidities and other co-existent medical conditions). The mechanism or risk factors for mRNA vaccine-related myocarditis or pericarditis are unknown, but previous studies have suggested autoimmune or delayed hypersensitivity responses to viral antigens.10,12 Therefore, long-term surveillance is needed to determine whether these conditions could be temporally related to the natural history of suspected myocarditis after mRNA vaccination or simple systemic vaccine-induced inflammatory response.
The short-term follow-up results of the total patients in this study showed that those with VAEs did not have higher rates of ER visit and death when compared to the control group. There was only one case of death in the VAE group which was due to pneumonia, thus not being related to mRNA vaccination. In a study conducted by Patone, et al.,19 outcome events were defined as admissions or deaths, with myocarditis-related outcomes and pericarditis-related outcomes among a total of 38615491 patients being 1615 and 1574, respectively. Other previous studies have also shown the mild clinical course and favorable outcomes in patients with post-vaccination myocarditis. In our study, the VAE group did show a higher hospitalization rate compared to the control group. However, most patients were hospitalized for close observation via outpatient clinic but did not require intensive treatment, with no events of fulminant myocarditis or pericarditis. Among the patients who underwent the regarding tests, most showed normal results in echocardiography, ECG, and laboratory tests. A recent nationwide study also showed the mild and favorable clinal course and outcomes of myocarditis patients who had previously received COVID-19 vaccination.13 The incidence was rare, being 1.08 cases per 100000 vaccinations, and was mainly associated with mRNA vaccines. As the patients in our study showed favorable clinical outcomes even though they were included from tertiary referral centers, careful clinical vigilance and early detailed investigation and clinical management in outpatient clinic setting can be considered safe and plausible in mRNA-VRCS patients.
This study had a few limitations, mostly due to its retrospective and descriptive design, as well as the data being merged from two different medical centers. First, imaging and cardiac laboratory data were not obtained for all study populations. Data were missing for many of the items related to the clinical course, including cardiac biomarkers, and diastolic function parameters of echocardiography were not assessed. In addition, we only studied the short-term course after vaccination, and did not obtain appreciable long-term follow-up results. In this study population, none of the enrolled patients underwent cardiac magnetic resonance imaging, and no patient underwent endomyocardial biopsy to rule out direct viral infection of the myocardium. This decision was made due to the relatively stable condition of the patients. Thus, absolute diagnosis of myocarditis was limited and the regarding cases were classified as probable myocarditis. Finally, the small sample size of the VAE group may have led to the insufficient results when compared to the group without adverse cardiovascular events groups after vaccination. Although a few variables of the laboratory test results were suspected to show difference between the study groups, there was no statistically significant difference. Despite the prognostic role of inflammatory biomarkers in the setting of COVID-19 pathophysiology,20,21 the laboratory test results were not statistically different between the two groups.
In conclusion, among the patients who experienced mRNA-VRCS and visited outpatient clinics, the total incidence of VAEs, including acute myocarditis and pericarditis, was 2.2%. Patients with VAEs showed higher rates of dyspnea, echocardiographic changes, and ST-T segment changes compared to those without VAEs. With or without cardiovascular events, the prognosis in patients with mRNA-VRCS was favorable with no significant difference in mortality rates. Outpatient clinical workup and management can be considered safe and reasonable in patients with cardiovascular symptoms after mRNA COVID-19 vaccination.
ACKNOWLEDGEMENTS
This study was supported by the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (HA21C0065).
Footnotes
The authors have no potential conflicts of interest to disclose.
- Conceptualization: William D. Kim, Min Jae Cha, Ji-won Hwang, and Iksung Cho.
- Data curation: Ji-won Hwang and Iksung Cho.
- Formal analysis: Subin Kim and Ji-won Hwang.
- Funding acquisition: Iksung Cho.
- Investigation: William D. Kim, Ji-won Hwang, and Iksung Cho.
- Methodology: Dong-Gil Kim, Jae-Jin Kwak, Sung Woo Cho, Joon Hyung Doh, and Sung Uk Kwon.
- Project administration: Ji-won Hwang and Iksung Cho.
- Resources: Min Jae Cha, Dong-Gil Kim, Jae-Jin Kwak, Sung Woo Cho, Joon Hyung Doh, Sung Uk Kwon, June Namgung, Sung Yun Lee, Jiwon Seo, Geu-ru Hong, Ji-won Hwang, and Iksung Cho.
- Software: Subin Kim.
- Supervision: Geu-ru Hong, Ji-won Hwang, and Iksung Cho.
- Validation: Dong-Gil Kim, Jae-Jin Kwak, Sung Woo Cho, Joon Hyung Doh, Sung Uk Kwon, June Namgung, Sung Yun Lee, Jiwon Seo, and Geu-ru Hong.
- Visualization: Subin Kim and Ji-won Hwang.
- Writing—original draft: William D. Kim, Ji-won Hwang, and Iksung Cho.
- Writing—review & editing: all authors.
- Approval of final manuscript: all authors.
SUPPLEMENTARY MATERIALS
Echocardiography, Electrocardiography, and Additional Cardiac Evaluation
Comparison of Baseline Comorbidity between Groups With and Without Vaccine-Related Adverse Events
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Associated Data
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Supplementary Materials
Echocardiography, Electrocardiography, and Additional Cardiac Evaluation
Comparison of Baseline Comorbidity between Groups With and Without Vaccine-Related Adverse Events