Myocarditis and pericarditis: reducing inflammation and supporting heart health

Myocarditis and pericarditis symptoms

Symptoms of myocarditis and pericarditis are similar and can be mistaken for heart attack. Pericarditis is one of the most common reasons for heart attack like pain presenting to hospital emergency departments. Therefore, it is always important to seek urgent medical care to rule out heart attack first.

Myocarditis symptoms

Myocarditis symptoms can include:

• Chest pain, or feeling of pressure
• Heart palpitations and abnormal rhythms
• Shortness of breath, especially during exercise, and at night
• Feeling lightheaded
• Fluid retention in arms and legs, particularly around ankles and feet
• Fainting, or sudden loss of consciousness
• Other symptoms of infection (body aches, joint pain, fever, sore throat)

The pericardium is a fluid-filled sac containing the heart that lubricates, protects it from infection, and keeps the heart from over expanding when blood volume increases. Inflammation of the pericardium often develops suddenly and can last several months. There can be extra fluid (called pericardial effusion) due to the inflammation causing back pressure on the heart, making contraction and expansion more difficult.

Pericarditis symptoms

Pericarditis symptoms include:

• Sharp, stabbing pain which may get worse with coughing, swallowing, lying down or taking deep breaths
• Pain in the back, neck or left shoulder
• It can be more comfortable to sit up, lean forward or bend over and hold your chest
• Anxiety
• Fatigue
• Difficulty breathing when lying down
• Dry cough
• Swelling in feet, legs and ankles
• Some people hear a sound of rubbing, or creaking from the chest or lungs, most often when leaning forward or breathing heavily
• Abnormal heart rhythm

Causes of myocarditis and pericarditis

The majority of cases of myocarditis and pericarditis are reported following viral infection. Symptoms commonly occur around 7-14 days after a viral infection.

Causes of Myocarditis

There are a number of classifications of myocarditis, with the most common being; acute (AM), active, chronic inflammatory cardiomyopathy (infl-CMP), chronic, immune-mediated, immune checkpoint-associated, virus induced, and lymphocytic myocarditis.

Most common triggers for AM and infl-CMP myocarditis are:

• Viruses – DNA viruses & RNA viruses including the common cold, influenza, respiratory infection, hepatitis B & C, measles, mumps, HIV, herpes simplex, rubella, Epstein Barr Virus (glandular fever / mononucleosis), parvovirus, COVID-19, long COVID and more
• Bacteria – streptococcus, staphylococcus, brucella, chlamydia and more
• Protozoa
• Fungi – (uncommon)
• Tick-borne pathogens – Borrelia burgdorferi (Lyme disease)

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Non-infectious myocarditis triggers include (much less common):

• Immune mediated – heart transplant rejection
• Autoimmune diseases
• Smallpox and tetanus vaccinations
• Drugs and toxic substances
• Heavy metals
• Environmental toxins
• Scorpion-bee wasp stings and spider or snake bites
• Allergic reactions
• Radiation
• Certain cancers

Causes of Pericarditis

The main types of pericarditis include; acute, chronic, cardiac tamponade (medical emergency), constrictive, infectious, idiopathic (unknown cause), traumatic and uremic pericarditis (due to kidney failure).

Pericarditis causes include:

• Viruses (most common) particularly affecting the gastrointestinal system
• Bacterial – tuberculosis is a major cause in developing countries
• Fungal (rare)
• Parasites

Non-infectious causes:

• Some cancers
• Autoimmune diseases – ankylosing spondylitis, systemic lupus erythematosus, rheumatoid arthritis, Behcet’s disease, myxedema and uremia
• Trauma, after surgery, accident, or heart attack
• Diseases such as familial Mediterranean fever
• Medications – such as immunosuppressants, for cancer or HIV

Whilst the evidence is limited, human studies support the theory that there is an interaction between gut microbiome dysbiosis, the immune system and susceptibility to cardiac inflammation. This is referred to as the heart-gut-immune axis.

Inflammation of the heart after COVID-19 infection or vaccine

Once thought of as rare, myocarditis is more common in young people aged 12-21, and 90% of cases are in males. More recently, there has been an increase in both cases and awareness of myocarditis and pericarditis due to COVID-19 infection and/or vaccination induced incidents. In Australia, in April 2022, the number of people treated for post-vaccination myocarditis was 1399, and these incidents are monitored closely by the Therapeutic Goods Administration (TGA). Less than 20% of COVID-19 vaccination induced myocarditis were admitted to hospital intensive care units in a USA study of 139 adolescents and young adults.

COVID-19 vaccine-induced myocarditis or pericarditis can affect any person, of any age or gender. However, internationally, the highest risk groups vary by country, vaccine type, gender, age and time between doses. The highest risk groups in Australia are reported as men under 40, between 1-5 days following the second dose of an mRNA vaccine. Moderna presents a higher risk than Pfizer or AstraZeneca vaccines, and the risk profile for Novavax is not yet known (though a small number of cases were detected in the clinical trial). The risk is much lower in children 5-11 years old, than in adolescents.

Most vaccine-related myocarditis cases have been designated as mild, with only brief periods of hospitalisation required for the majority.

Children and adolescents who present to hospital with chest pain or other symptoms of myocarditis or pericarditis, having received Moderna / Pfizer vaccinations within 14 days are treated using a specific algorithm. The Dept. of Health recommends ensuring an 8 week interval between doses one and two of Moderna and Pfizer vaccines for ages 5 -11, and especially for males aged 12-39 years. Subsequent vaccinations of people who have had pericarditis should be assessed depending on inflammatory markers, and have been symptom free for 6 weeks or more. Assessment is made case by case for those with vaccine-induced myocarditis.

COVID-19 natural infection induced myocarditis is becoming more common, however, case numbers are not accurate as confirmed diagnosis requires an MRI, which is not conducted in all cases. Predominantly, male patients were affected in a review of studies in July 2020, and it is suspected that around 30% of COVID-19 patients experience heart injury. Severity of disease does not determine the likelihood of developing myocarditis.

COVID-19 natural infection-induced pericarditis is less common, and more often present as myopericarditis (i.e. alongside myocarditis).

The Dept of Health strongly recommends vaccination of all individuals to reduce the risk of hospitalisation and death from COVID-19. The incidence of vaccine-induced pericarditis or myocarditis is very low, however, this does not diminish the debilitating effect it has on health and daily life for those affected.

Conventional treatment for myocarditis and pericarditis

Conventional treatment for myocarditis and pericarditis starts with investigations to determine the diagnosis, such as:

• Physical examinations
• Blood tests to look for inflammation
• CT scans
• Cardiac MRI
• Echocardiogram
• Chest X rays
• Electrocardiogram
• Occasionally, a heart biopsy is required to confirm myocarditis diagnosis

Once diagnosed, medications are usually prescribed for:

• Pain relief, such as over the counter non-steroidal anti-inflammatory drugs (NSAIDs), ibuprofen or aspirin or paracetamol
• Treating infection – antibiotics, or antifungal medications
• Reducing recurrent episodes – Colchicine
• Reducing inflammation – corticosteroids
• Reducing oedema / fluid retention – diuretics

In extreme cases, surgery may be required to drain fluid from around the heart in people with severe pericarditis. In some people with constrictive pericarditis, a small amount of the pericardium may need to be removed to prevent further constriction around the heart.

If the heart is severely weakened in myocarditis, medical devices such as defibrillators, ventricular assist devices, and extracorporeal membrane oxygenation machines may be required to help restore proper function. If medications and devices aren’t sufficient, then a heart transplant may be required.

Most patients recover fully from both conditions, however, some need to modify their lifestyle due to long lasting symptoms such as avoiding strenuous exercise, reducing salt and fluids, eliminating alcohol consumption and smoking. Some patients require lifelong medications.

Many of the pharmaceutical medications used to treat myocarditis and pericarditis have undesirable side effects, which is why many people seek a more natural treatment for myocarditis and pericarditis.

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