| Myocarditis and other myocardial involvement |
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Myocarditis is defined by: 1) cardiac symptoms (eg, chest pain, dyspnea, palpitations, syncope); 2) an elevated cTn; and 3) abnormal electrocardiographic, echocardiographic, CMR, and/or histopathologic findings on biopsy or postmortem evaluation in the absence of flow-limiting coronary artery disease.
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When there is increased suspicion for cardiac involvement with COVID-19, initial testing should consist of an ECG, measurement of cTn (preferably using a high-sensitivity assay), and an echocardiogram.
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Cardiology consultation is recommended for those with a rising cTn and/or ECG or echocardiographic abnormalities concerning for myocarditis.
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CMR is recommended in hemodynamically stable patients with suspected myocarditis.
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Hospitalization is recommended for patients with definite myocarditis that is either mild or moderate in severity, ideally at an advanced heart failure center. Patients with fulminant myocarditis should be managed at centers with an expertise in advanced heart failure, mechanical circulatory support, and other advanced therapies.
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Patients with myocarditis and COVID-19 pneumonia (with an ongoing need for supplemental oxygen) should be treated with corticosteroids.
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For patients with suspected pericardial involvement, treatment with NSAIDs, colchicine, and/or prednisone is reasonable.
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Intravenous corticosteroids may be considered in those with suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or MIS-A. Empiric use of corticosteroids may also be considered in those with biopsy evidence of severe myocardial infiltrates or fulminant myocarditis, balanced against infection risk.
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As appropriate, guideline-directed medical therapy for heart failure should be initiated and continued after discharge.
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Myocarditis following COVID-19 mRNA vaccination is rare. The highest observed rates have been in young male individuals (aged 12-17 years) after the second vaccine dose.
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COVID-19 vaccination is associated with a very favorable benefit-to risk ratio for all age and sex groups evaluated thus far.
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In general, vaccine-associated myocarditis should be diagnosed, categorized, and treated in a manner analogous to myocarditis following SARS-CoV-2 infection.
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| PASC |
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PASC is defined as a constellation of new, returning, or persistent health problems experienced by individuals 4 or more weeks after SARS-CoV-2 infection.
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PASC-CVD refers to a broad group of cardiovascular conditions that include, but are not limited to, myocarditis and other forms of myocardial involvement, pericarditis, new or worsening myocardial ischemia, microvascular dysfunction, nonischemic cardiomyopathy, thromboembolism, cardiovascular sequelae of pulmonary disease, and arrhythmia.
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PASC-CVS is a heterogeneous disorder that includes widely-ranging cardiovascular symptoms, without objective evidence of cardiovascular disease using standard diagnostic testing. Common symptoms include tachycardia, exercise intolerance, postexertional malaise, palpitations, chest pain, and dyspnea.
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For patients with cardiovascular symptoms and suspected PASC, a reasonable initial testing approach includes: 1) basic laboratory testing (including cTn); 2) an ECG; 3) an echocardiogram; 4) an ambulatory rhythm monitor; 5) chest imaging (X-ray and/or CT); and/or 6) pulmonary function tests.
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Cardiology consultation is recommended for patients with PASC that have: 1) abnormal cardiac test results; 2) known cardiovascular disease with new or worsening symptoms or signs; 3) documented cardiac complications during SARS-CoV-2 infection; and/or 4) persistent cardiopulmonary symptoms that are not otherwise explained.
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Recumbent or semi-recumbent exercise (eg, rowing, swimming, or cycling) is recommended initially for PASC-CVS patients with tachycardia, exercise/orthostatic intolerance, and/or deconditioning, with transition to upright exercise as orthostatic intolerance improves. Exercise duration should also be short (5-10 minutes/day) initially, with gradual increases as functional capacity improves.
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Salt and fluid loading represent nonpharmacological interventions that may provide symptomatic relief for patients with tachycardia, palpitations, and/or orthostatic hypotension. Beta-blockers, nondihydropyridine calcium-channel blockers, ivabradine, fludrocortisone, and midodrine may be used empirically as well.
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| RTP |
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Athletes who are asymptomatic after recent SARS-CoV-2 infection may resume exercise training after 3 days of exercise abstinence during self-isolation.
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Athletes with mild or moderate non-cardiopulmonary symptoms after recent SARS-CoV-2 infection may resume exercise training after their symptoms have resolved.
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Athletes with remote infection (≥3 months) without ongoing cardiopulmonary symptoms may resume exercise training without the need for additional testing.
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Athletes recovering from COVID-19 with ongoing cardiopulmonary symptoms (chest pain/tightness, palpitations, or syncope) and/or those requiring hospitalization with increased suspicion for cardiac involvement should undergo triad testing (ECG, cTn, and echocardiogram). Triad testing should also be performed in those developing new cardiopulmonary symptoms after resumption of exercise training.
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CMR is recommended if triad testing is abnormal or cardiopulmonary symptoms persist.
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Athletes with myocarditis should abstain from exercise for 3-6 months.
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Maximal-effort exercise testing and/or an ambulatory rhythm monitor may be helpful in the evaluation of athletes with: 1) persistent cardiopulmonary symptoms and 2) either normal CMR or CMR that demonstrates other forms of myocardial (or pericardial) involvement. Maximal-effort exercise testing should only be performed, however, after myocarditis has been excluded with CMR.
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CMR to screen athletes who are asymptomatic or with non-cardiopulmonary symptoms is likely to be low yield.
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Repeat cardiac testing is not warranted in athletes with recurrent COVID-19 in the absence of cardiopulmonary symptoms.
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