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 Canadian Journal of Cardiology 37 (2021) 1629−1634

Training/Practice
Practical Clinical Practice Update
Myocarditis and Pericarditis After COVID-19 mRNA
Vaccination: Practical Considerations for Care Providers
Adriana Luk, MD, FRCPC, MSc,a,b Brian Clarke, MD, FRCPC, FACC,c
Nagib Dahdah, MD, MBA, FRCPC, FACC,d Anique Ducharme, MD, FRCPC,e
Andrew Krahn, MD,f Brian McCrindle, MD, MPH,g Trent Mizzi, BSc, MD, FRCPC,h
Monika Naus, MHSc, MD, FRCPC, FACPM,i Jacob A. Udell, MD, MPH, FRCPC,j
Sean Virani, MD, MSc, MPH, FRCPC, FCCS,f Shelley Zieroth, MD,k and
Michael McDonald, MD, FRCPCa
a
Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; b Division of Cardiology, Mount Sinai Hospital, Sinai
Health System, Toronto, Ontario, Canada; c Libin Cardiovascular Institute, Foothills Medical Centre, Calgary, Alberta, Canada; d Division of Pediatric Cardiology,
Department of Pediatrics, CHU Sainte Justine, University of Montreal, Montreal, Quebec, Canada; e Institut de Cardiologie de Montr
e al, Universit
e de Montr
e al,
Montr
e al, Qu
e bec, Canada; f Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; g The
Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; h Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick
Children, University of Toronto, Toronto, Ontario, Canada; i Communicable Diseases and Immunization Service, British Columbia Centre for Disease Control,
Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; j Division of
Cardiology, Women’s College Hospital and Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; k University of Manitoba, Winnipeg,
Manitoba, Canada

ABSTRACT

RESUM

E
The mRNA vaccines against COVID-19 infection have been effective in Les vaccins a  ARNm contre la COVID-19 ont permis de re
duire effi-
reducing the number of symptomatic cases worldwide. With wide- cacement le nombre de cas symptomatiques de cette infection dans
spread uptake, case series of vaccine-related myocarditis/pericarditis le monde entier. Par suite de l’usage ge
ne
ralise

du vaccin, une se
rie
have been reported, particularly in adolescents and young adults. Men de cas de myocardite ou de pe
ricardite lie
es au vaccin a e
te

signale

e,
tend to be affected with greater frequency, and symptom onset is usu- en particulier chez les adolescents et les jeunes adultes. Le
ally within 1 week after vaccination. Clinical course appears to be mild phe
nome ne tend a toucher plus fre
quemment les sujets de sexe mas-
in most cases. On the basis of the available evidence, we highlight a culin, et les sympto ^mes apparaissent ge
ne

ralement au cours de la
clinical framework to guide providers on how to assess, investigate, semaine suivant la vaccination. L’e
volution clinique semble be
nigne
diagnose, and report suspected and confirmed cases. In any patient s grande majorite
dans la tre
des cas. A partir des donne
es disponibles,
with highly suggestive symptoms temporally related to COVID-19 nous de
gageons un cadre de re
fe

rence clinique auquel les fournis-
mRNA vaccination, standardized workup includes serum troponin seurs pourront se reporter au moment d’e
valuer, d’examiner, de diag-
measurement and polymerase chain reaction testing for COVID-19 nostiquer et de signaler les cas suspects et confirme
s. Chez tout
infection, routine additional lab work, and a 12-lead electrocardio- patient qui a des sympto ^mes fortement e
vocateurs et pre
sentant un
gram. Echocardiography is recommended as the imaging modality of lien temporel avec l’administration du vaccin a  ARNm contre la
choice for patients with unexplained troponin elevation and/or patho- COVID-19, le bilan diagnostique syste
matique comprend le dosage de
logic electrocardiogram changes. Cardiovascular specialist consulta- la troponine se
rique et le de

pistage de la COVID-19 par PCR, d’autres
tion and hospitalization should be considered on the basis of the analyses de laboratoire courantes et un e
lectrocardiogramme (ECG) a 
results of standard investigations. Treatment is largely supportive, and 12 de
rivations. L’e
chocardiographie est la technique d’imagerie

The mRNA vaccines against COVID-19 have shown unprec- infection and severe illness. With the development of
edented efficacy with respect to prevention of symptomatic COVID-19 variants of concern including variant B.1.617.2
for which 2 vaccinations are needed to confer immunity, con-
tinued public health initiatives promoting vaccine use has
Received for publication July 20, 2021. Accepted August 1, 2021. continued. Recently, an association with myocarditis and peri-
Corresponding author: Dr Michael McDonald, Division of Cardiology, carditis has been reported to be related to mRNA vaccina-
Peter Munk Cardiac Centre, 585 University Ave, Toronto General Hospital, tion.1 Historically, myocarditis/pericarditis has been reported
Toronto, Ontario M5G 2C4, Canada.
E-mail: [email protected]
after a smallpox live vaccine, with an incidence of 2.16-7.8
See page 1634 for disclosure information. per 100,000 vaccines with reports occurring up to 30 days

https://doi.org/10.1016/j.cjca.2021.08.001
0828-282X/© 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1630 Canadian Journal of Cardiology
Volume 37 2021

myocarditis/pericarditis that is diagnosed according to defined clinical recommande
e en premie re intention chez les patients pre

sentant une
criteria should be reported to public health authorities in every jurisdic- hausse inexplique
e du taux de troponine et/ou des modifications
tion. Finally, we recommend COVID-19 vaccination in all individuals in pathologiques du trace
de l’ECG. La consultation d’un spe
cialiste en
accordance with the Health Canada and National Advisory Committee soins cardiovasculaires et l’hospitalisation devraient e ^tre envisage
es
on Immunization guidelines. In patients with suspected myocarditis/ en fonction des re
sultats des examens standard. Le traitement est en
pericarditis after the first dose of an mRNA vaccine, deferral of a sec- grande partie axe
sur les soins de soutien, et les cas de myocardite ou
ond dose is recommended until additional reports become available. de pe
ricardite diagnostique
s selon des criteres cliniques de
finis dev-
^tre signale
raient e
s aux autorite
s de sante

publique locales partout au
pays. Enfin, nous recommandons la vaccination de chaque personne
contre la COVID-19, conforme
ment aux lignes directrices de Sante

Canada et du Comite
consultatif national de l'immunisation. En ce qui
concerne les patients chez qui une myocardite ou une pe
ricardite est
soupçonne
e apres l’administration de la premie re dose d’un vaccin a 
ARNm, il est recommande
de reporter l’administration de la seconde
dose jusqu’a ce que des donne
es supple

mentaires soient disponibles.

post vaccination. Most of these patients recover without any frequent than in women). Similar to previous reports of myocardi-
long-term sequelae. Other live viral vaccines (including mea- tis/pericarditis with other vaccines, one suspects that there is likely
sles-mumps-rubella, varicella, oral polio, or yellow fever vac- under-reporting of the true incidence on the basis of subclinical
cine) have a lower incidence of myocarditis/pericarditis (0.24 disease. Through June 5, 2021, an incidence of 12.6 cases per mil-
per 100,000 vaccines). The likelihood of an association lion second doses in the 12- to 39-year-old age group was
between COVID-19 mRNA vaccines and myocarditis/peri- observed in the 21 days after vaccination, with clustering within
carditis has understandably generated significant interest the first 6 days.1 Surveillance data in Canada (up to July 9, 2021)
among health care providers, the scientific community, and includes 163 cases of myocarditis/pericarditis, where cases have
the public. This issue is particularly germane during this phase been seen after the first and second dose of vaccine, and between
of the pandemic with public health efforts increasingly 5 hours and 92 days post exposure.2 These clinical findings are
focused on vaccination of adolescents and young adults, and similar to multiple series reported worldwide. The references for
because further expansion of vaccine efforts in children youn- these cases series are included in Supplemental Appendix S1. To
ger than 12 years of age is anticipated in the coming months. date, myopericarditis has been reported to occur after both avail-
The aim of this commentary is to provide a real-time prag- able mRNA vaccines (Moderna and Pfizer-BioNTech).
matic framework for cardiovascular care providers in Canada
to address concerns of myocarditis/pericarditis potentially
related to mRNA vaccination. The author group includes
expertise in adult and pediatric cardiology, primary care,
emergency medicine, policy, public health and vaccinology.
Herein, we summarize the current state of knowledge regard-
ing incidence and preliminary outcomes of mRNA vaccine- Case Definitions
related myocarditis/pericarditis, address the evaluation, man- Standardized case definitions are important to understand
agement, and reporting of suspected cases, and provide a sug- the true incidence of myocarditis and pericarditis after mRNA
gested approach to informed decision-making with patients COVID-19 vaccination. This poses a number of challenges: the
who receive the COVID-19 mRNA vaccination. World Health Organization Global Advisory Committee on
We recognize that this is a rapidly evolving area of great Vaccine Safety uses the Brighton Collaboration case definition
interest to multiple stakeholders, especially young patients for myocarditis, which discriminates 5 levels of certainty for the
and their families, and our understanding of the link between diagnosis. As a comparison, the Vaccine Adverse Events Report-
myocarditis/pericarditis and mRNA vaccines will likely be ing System in the United States draws from historic case defini-
informed by new and emerging data. This commentary has tions for myocarditis, categorizing events as suspected, probable,
been endorsed by the Canadian Cardiovascular Society’s or confirmed—the latter specifically requires the presence of
COVID-19 Rapid Response Team and by the Canadian Pedi- pathognomonic histological findings of myocardial inflamma-
atric Cardiology Association. tion to be present at biopsy or autopsy. In the Vaccine Adverse
Events Reporting System, events may be self-reported and adju-
dication is challenging in the absence of medical records review
Myocarditis/Pericarditis and COVID-19 mRNA and confirmatory diagnostic testing. Finally, and most relevant
Vaccines to the practitioner, myocarditis and pericarditis diagnostic crite-
Ongoing surveillance of COVID-19 mRNA vaccines has ria for the purpose of direct patient care might be different from
identified potential post-vaccination adverse events. Recently, data those used by surveillance systems to classify a reported event
presented to the Advisory Committee on Immunization Practices with respect to certainty of diagnosis. In this regard, the Centers
by the Centers for Disease Control and Prevention reported on for Disease Control and Prevention working case definition for
incidence of myocarditis/pericarditis after approximately myocarditis, which categorizes cases as probable or confirmed,
300,000,000 COVID-19 mRNA doses in the United States. best aligns with our understanding of how myocarditis is cur-
Cases were much more common after the second dose, with a pre- rently worked up in Canada (a summary of the case definitions
ponderance of men affected (approximately 5-10 times more and references are shown in Supplemental Table S1).
Luk et al. 1631
Myocarditis/Pericarditis After COVID-19 mRNA Vaccine

Reporting broad and includes infectious causes (viral, bacterial, fungal),

Adverse events after immunization should be reported to including acute COVID-19 infection, or post-COVID-19
the Public Health authority, which in most provinces and ter- Multisystem Inflammatory Syndrome in Children (MIS-C)/
ritories is the local Medical Officer of Health (https://www. Adults, drugs and toxins, systemic autoimmune disease, or
canada.ca/en/public-health/services/immunization/federal-pro specific etiologies such as sarcoidosis and giant cell myocardi-
vincial-territorial-contact-information-aefi-related-questions. tis. Due diligence must be maintained to rule out other causes
html). This is important for detection of potential safety sig- depending on the clinical presentation; myocardial ischemia
nals as well as future immunization recommendations for the due to coronary disease might also need to be considered in
individual recipient. Health care providers should report any young persons with symptoms indicative of myocarditis/peri-
serious or unusual events suspected to be associated with vac- carditis.
cination. Definitive proof of a causal association is not neces- Suggested evaluation of a patient with high pretest proba-
sary, and for many events, cannot be obtained; however, bility of myocarditis/pericarditis should follow a rational clin-
events with a clear alternate explanation should not be ical approach (Table 1, Fig. 1). Careful history and physical
reported. Myocarditis/pericarditis is not a listed adverse event examination are indicated for all patients with careful atten-
on the current reporting forms in most jurisdictions because tion to timing of and type of antecedent vaccination. Most
these are on the basis of the national form (https://www.can reports suggest that typical onset of myocarditis/pericarditis
ada.ca/content/dam/phac-aspc/documents/services/immuniza symptoms occurs within 5 days after COVID-19 mRNA vac-
tion/aefi-form-july23-2020-eng.pdf), but should be reported cine exposure. Initial evaluation should include an ECG and
as “Other events—Other serious or unexpected events not laboratory tests: complete cell count, electrolytes, renal func-
listed on the form.” tion, liver function tests, C-reactive protein and troponin,
All Canadian provinces and territories report into the and COVID-19 polymerase chain reaction testing. Clinically
Canadian Adverse Events Following Immunization Surveil- significant myocarditis is unlikely in the setting of a normal
lance System, the national system for detection of serious and ECG and cardiac biomarkers. Normal troponin level and a
rare events that generates estimates of incidence (https:// normal ECG on presentation does not exclude isolated peri-
www.canada.ca/en/public-health/services/immunization/cana carditis. Treatment should be started if there is a high index
dian-adverse-events-following-immunization-surveillance-sys of suspicion. The need for more extensive cardiac imaging
tem-caefiss.html). The Canadian Adverse Events Following and additional testing will depend upon the results of the
Immunization Surveillance System has issued weekly summa- screening tests as listed. Echocardiography should be per-
ries of reported adverse events with a focus on serious events formed in cases compatible with myocarditis/pericarditis,
and adverse events of special interest. This process also especially in the setting of an elevated troponin level (in the
informs Health Canada, the vaccine regulatory authority, absence of an alternative explanation). Cardiac magnetic reso-
with responsibility for initial authorization of products for use nance imaging may be considered where available and where
and periodic updates to the product monograph including an effect on management can reasonably be expected (ie,
safety findings. Such updates have been made several times when echocardiography is normal with elevated troponin
since initial emergency use authorizations of the COVID-19 level, yet clinical suspicion remains high). Coronary artery
vaccines, initially for the AstraZeneca/COVISHIELD vac- imaging should be considered in appropriate cases to rule out
cines for thrombosis with thrombocytopenia syndrome and myocardial infarction as a cause of biomarker/ECG abnor-
capillary leak syndrome, and most recently for the mRNA vac- malities. An assessment flow diagram is presented in Supple-
cines with respect to myocarditis/pericarditis. Clinicians can mental Figure S1.
remain current with such safety signals through subscribing to
the MedEffect Canada system (https://www.canada.ca/en/
health-canada/services/drugs-health-products/medeffect-can Management of mRNA Vaccine-Related
ada.html). Myocarditis/Pericarditis
There is no clear evidence to support the use of anti-
inflammatory therapy for all patients with myocarditis/peri-
Evaluation of Suspected Myocarditis/Pericarditis carditis. Spontaneous resolution of symptoms is reportedly
Patients with suspected myocarditis or pericarditis after prevalent. Overall, the therapeutic approach for symptomatic
vaccination do not usually require extensive evaluation if patients might include pain management and nonsteroidal
symptoms are mild. Myocarditis/pericarditis should be sus- anti-inflammatory agents with or without colchicine (the lat-
pected in patients who present with symptoms of chest pain, ter suggested particularly when pericarditis is the predominant
shortness of breath, palpitations, syncope, diaphoresis, or presentation). Use of intravenous immune globulins, cortico-
fatigue without obvious cause, which are also associated with steroids, and biologic immune-modulating agents have been
evidence of myocardial injury by elevation in cardiac bio- reported, and might be considered in severe cases.
markers (ie, a serum troponin level). Serum troponin level ele- For rare cases of hemodynamic instability requiring inotro-
vations in myocarditis are often significant (> 10 times the pic support, patients should be managed at tertiary care
upper limit of normal) in patients with myocarditis. Electro- centres with the capacity for managing cardiogenic shock and
cardiogram (ECG) changes are common and include ST ele- critically ill cardiac patients. Supportive measures might
vation in multiple leads, nonspecific ST/T changes, and include inotropic/vasoactive drugs, antithrombotic therapy,
diffuse T-wave inversions. The differential diagnosis remains mechanical ventilation, or mechanical circulatory support
1632 Canadian Journal of Cardiology
Volume 37 2021

Table 1. Evaluation of symptomatic patients with suspected myocarditis/pericarditis

Investigation Potential findings Clinical indication
History and physical exam Symptom onset temporally related to vaccination All patients with symptoms potentially related to
 Typical onset within first week post doseScreening myocarditis/pericarditis temporally related to COVID-
history for alternative diagnosesHistory of previous 19 mRNA vaccine
COVID-19 infection or potential exposuresCommon
symptoms suggestive of myocarditis/pericarditis:
 Chest pain
 Dyspnea
 Palpitations
 Syncope
 Diaphoresis
 Myalgias
Exam focused on hemodynamic status of patient, evidence
for heart failure, pericardial rub, evidence of systemic ill-
ness, or alternate cause
ECG ST elevation All patients with symptoms potentially related to
 Suggests pericardial involvement or acute transmural myocarditis/pericarditis temporally related to COVID-
myocardial injury 19 mRNA vaccine
 ST depression/T wave inversions
 Nonspecific in setting of suspected myocarditis/
pericarditis
Second- or third-degree AV block or tachyarrhythmias
Routine lab work Cardiac biomarkers All patients with symptoms potentially related to
 Troponin elevation might be > 10 times ULN myocarditis/pericarditis temporally related to COVID-
CRP 19 mRNA vaccination
 Elevated inflammatory markers are suggestive but not
specific for myocarditis/pericarditis
COVID-19 PCR testing
 Positive test suggests acute or recent COVID-19
infection
 Serology testing might be misleading in the setting of
vaccination or previous exposure to COVID-19
CBC, LFTs, creatinine
 Abnormalities might be nonspecific. Markers of end
organ dysfunction assessment should consider the
hemodynamic status of the patient
Echocardiogram Normal biventricular function does not rule out Patients with moderate-high index of suspicion on the
myocarditis/pericarditis basis of clinical scenario, ECG, and troponin level
Reduced LV/RV function might reflect more severe elevation
myocarditisPericardial effusion suggestive of pericarditis
 Pericardial effusions should be followed on the basis of
the clinical setting to rule out progression

Cardiac MRI Findings might not be specific for vaccine-related Consider where available for symptomatic patients for
myocarditis whom diagnosis cannot be established with clinical
 Subepicardial or midmyocardial pattern of LGE scenario/ECG/labs/echocardiography
 Myocardial edema on T2 imaging

Coronary artery assessment Normal arteries suggestive of noncoronary cause for Consider for patients with symptoms suggestive of
 Invasive coronary angiography presentation ischemia with typical evolution of cardiac biomarkers
 CT coronary angiography Thrombotic occlusion, vasospasm, or dissection suggestive and/or ECG changes suggestive of ischemia
of primary coronary etiology Need to consider pretest likelihood of coronary disease in
all cases
Endomyocardial biopsy Might be normal despite clinical picture consistent with Rarely indicated
myocarditis  Consider only when specific etiology of myocarditis is
Changes consistent with myocarditis might be seen being considered and results would determine further
therapy
 Consider if the patient presents with severe/fulminant
myocarditis with hemodynamic instability or if
clinical deterioration despite supportive care

Included are the clinical indications for diagnostic testing and the findings that might be seen in a patient with myocarditis/pericarditis.
AV, atrioventricular; CBC, complete blood count; CRP, C-reactive protein; CT, computed tomography; ECG, electrocardiogram; LFTs, liver function tests;
LGE, late gadolinium enhancement; LV, left ventricle; MRI, magnetic resonance imaging; mRNA, messenger ribonucleic acid; PCR, polymerase chain reaction;
RV, right ventricle; ULN, upper limit of normal.

including extracorporeal membrane oxygenation. For patients provide guidance on further imaging/evaluation, treatment,
recovering from significant illness, follow-up should be coor- and return to regular activities because strenuous exercise
dinated in consultation with a cardiovascular specialist to should be avoided until follow-up assessment.
Luk et al. 1633
Myocarditis/Pericarditis After COVID-19 mRNA Vaccine

Figure 1. A summary of the clinical considerations for diagnosis and reporting of a patient with COVID-19 mRNA vaccine myocarditis/pericarditis.
https://wepik.com/. CBC, complete cell count; CDC, Centers for Disease Control and Prevention; Cr, creatinine; CRP, C-reactive protein; ECG,
electrocardiogram; LFTs, liver function tests; mRNA, messenger ribonucleic acid; PCR, polymerase chain reaction; TTE, transthoracic echocardio-
gram.

Recommendations regarding further COVID-19 mRNA This syndrome can result in a severe clinical course requiring
vaccination for those with confirmed myocarditis/pericarditis intensive care management. Cardiovascular complications
will evolve as evidence emerges. In the near term, it might be from MIS-C include cardiac dysfunction (40.6%), shock
prudent to defer or delay the second or subsequent vaccine (35.4%), pericardial effusion (23.9%), mitral regurgitation
doses in accordance with the National Advisory Committee (25.5%), myocarditis (22.8%), heart failure (7.0%), and coro-
on Immunization (NACI) guidance.3 nary artery dilatation or aneurysm (18.6%), with a mortality
rate of 1%-2%.5 In light of current knowledge, it is reasonable
to consider that despite the rarity of potential adverse out-
COVID-19-Related Cardiovascular Complications comes after COVID-19 mRNA vaccine-related myocarditis/
Consideration of risks with COVID-19 mRNA vaccina- pericarditis in adults and children, the benefits from the vac-
tion have to be balanced against the risks of complications cine in avoiding COVID-19 infection and its related compli-
from COVID-19 infection. Proposed mechanisms of cardiac cations outweigh the risk.
involvement in those infected with COVID-19 include sym-
pathetic stimulation, proinflammatory effects, myocyte necro- Summary and Guidance
sis leading to myocarditis, and heightened risk of arrhythmia On the basis of the current state of knowledge regarding
and left ventricular dysfunction. In addition, the hypercoagu- the potential association between mRNA vaccination and
lable state associated with COVID-19 infection, along with myocarditis/pericarditis, “take away messages” for cardiovas-
direct vascular infection and concomitant cellular inflamma- cular care providers can be articulated. These include:
tion, contributes to higher risk of myocardial infarction.
Multiple studies have reported on the prevalence of cardiac
complications in adults after COVID-19 infection, which
include heart failure (23%-33.3%), myocardial injury/myo-  The estimated incidence of myocarditis/pericarditis after
carditis (8%-27.8%), arrhythmia (16.7%), and thromboem- COVID-19 mRNA vaccination across different age groups is
bolism (31%-40%). In those who develop myocarditis with likely to change with additional data; at present this is a rare
elevated inflammatory biomarkers (leukocytosis, lymphope- event, with most reports suggesting incidence of 1 case per
nia, d-dimer, C-reactive proteins, and pro-calcitonin) and ele- 10,000-100,000 vaccinations.
vated troponin levels, high mortality rates (51%-97%) have  Most myocarditis/pericarditis cases have been reported after a
been described in several cases series.4 second dose of COVID-19 mRNA vaccination, with greater
In contrast to adults, children have been largely spared incidence in men. Presentation is usually early (within the first
COVID-19-related acute pulmonary infection and associated week) after vaccination.
complications. However, children are vulnerable to a post  Most myocarditis/pericarditis cases reported have been mild and
exposure hyperinflammatory syndrome known as MIS-C. self-limited. Severe cases that present as more fulminant
1634 Canadian Journal of Cardiology
Volume 37 2021

myocarditis with cardiogenic shock are exceedingly rare and vaccine are outweighed by the well defined risks of COVID-
likely merit more extensive investigation to exclude other 19 infection. Vaccination continues to be recommended in all
causes. eligible individuals. A thoughtful approach to evaluation,
 The approach to investigation should be tailored to the clinical management, and reporting of suspected cases of myocarditis/
presentation. Suspected cases require a careful history and physi- pericarditis is indicated as a key public health measure.
cal exam, ECG, routine laboratory work, and consideration for
echocardiography. Patients with significant symptoms and rou-
tine testing supportive of a diagnosis of myocarditis/pericarditis Acknowledgements
should undergo additional cardiac investigations with special- The authors acknowledge members of the Canadian Car-
ized testing on the basis of availability and likelihood of an effect diovascular Society’s COVID-19 Rapid Response team in
on clinical management. addition to Dr Kenny Wong (on behalf of the Canadian Pedi-
 Suspected cases should be reported to the Public Health Adverse atric Cardiology Association) for their review of an earlier ver-
Event Following Immunization Reporting System (https:// sion of this report.
www.canada.ca/en/public-health/services/immunization/report
ing-adverse-events-following-immunization.html) by the health Funding Sources
care provider of record. None.
 No specific therapy can be recommended at present and care is
largely supportive. A cardiac care provider should assess patients
who require admission to hospital to provide guidance on moni- Disclosures
toring, further management, and post-discharge follow-up The authors have no conflicts of interest to disclose.
instructions.
 COVID-19 mRNA vaccination is recommended in all popula-
tions for which a benefit has been established, in accordance References
with Health Canada and NACI guidelines. On the basis of our 1. Shimabukuro T. COVID-19 Vaccine Safety Updates. Available at:
current knowledge, the benefits of COVID-19 vaccination in https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-06/
all age groups far outweigh the potential risks of mRNA vaccina- 03-COVID-Shimabukuro-508.pdf. Accessed June 27, 2021.
tion and that of possible COVID-19 infection in susceptible 2. Government of Canada. Reported side effects following COVID-19 vacci-
individuals. nation in Canada. Available at: https://health-infobase.canada.ca/covid-
 For patients with myocarditis/pericarditis temporally associ- 19/vaccine-safety/. Accessed July 16, 2021.
ated with the first dose of COVID-19 mRNA vaccination,
available evidence is currently insufficient to support any 3. Public Health Agency of Candada. Summary of National Advisory Com-
mittee on Immunization (NACI) Updates of July 2, 2021. Available at:
clinical practice recommendations. Questions remain as to
https://www.canada.ca/content/dam/phac-aspc/documents/services/immu
whether these patients should avoid a second vaccination, nization/national-advisory-committee-on-immunization-naci/recommen
have further delay between doses, or have a non-mRNA dations-use-covid-19-vaccines/summary-updates-july-2-2021-en.pdf.
vaccine as a second dose. Accessed July 21, 2021.
 As a precaution, and in accordance with NACI recommenda-
tions, patients with established myocarditis/pericarditis after the 4. Chang WT, Toh HS, Liao CT, Yu WL. Cardiac involvement of COVID-
19: a comprehensive review. Am J Med Sci 2021;361:14–22.
first mRNA vaccination should defer a second dose indefinitely
pending additional data. 5. Godfred-Cato S, Bryant B, Leung J, et al. COVID-19−associated multi-
system inflammatory syndrome in children—United States, March-July
2020. MMWR Morb Mortal Wkly Rep 2020;69:1074–80.

Conclusion
On the basis of our current state of knowledge, the associa- Supplementary Material
tion between myocarditis/pericarditis and COVID-19 mRNA To access the supplementary material accompanying this
vaccines in children and younger adults merits careful consid- article, visit the online version of the Canadian Journal of
eration for practitioners. Cases tend to be mild, do not usually Cardiology at www.onlinecjc.ca and at doi:10.1016/j.
require specific interventions, and potential risks of the cjca.2021.08.001.