Discussion:
The coronavirus infection 2019 (COVID-19), which is caused by SARS-CoV-2, causes mainly respiratory tract symptoms. While much of the focus has been on pulmonary complications, emergency clinicians need to be aware of the cardiovascular complications as well, which can be a significant contributor to the deaths associated with this disease.
Cardiovascular complications that are associated with COVID-19 include arrhythmias, acute myocardial infarction, myocarditis, heart failure and thromboembolic events.
These complications could be explained by many mechanisms such as; plaque rupture and coronary thrombosis, exaggerated immune response, direct myocardial injury, systemic inflammation, altered myocardial demand-supply ratio, electrolyte imbalances or adverse effects of therapies. 7
Acute pericarditis, which is an inflammation of the sac surrounding the heart, is a rare extrapulmonary complication of COVID-19. Generally, the aetiology of pericarditis could be classified into infectious and non-infectious. 8 They depend on the clinical context and epidemiological framework. In developing countries, viral infections represent the most common cause, whereas tuberculosis is the commonest cause globally.
Generally, it is postulated that viruses can cause pericardial inflammation via direct cytotoxic effects or immune-mediated mechanisms.9 COVID-19 has been stated to trigger an exaggerated systemic inflammatory response in certain patients. 10likewise in other viral infections, this inflammatory response could lead to pericarditis and the consequent pericardial effusion; however, the exact mechanism is be explained.
According to European Society of Cardiology (ESC) guidelines, the diagnosis of acute pericarditis depends on the presence of at least two out of four criteria: pericarditic chest pain, pericardial rub, new widespread ST-segment elevation or PR depression and new or worsening pericardial effusion. Elevation of inflammatory markers (white blood cell count, C-reactive protein and erythrocyte sedimentation rate), and evidence of pericardial inflammation on computed tomography (CT), cardiac magnetic resonance (CMR) can support the diagnosis of acute pericarditis.
The mainstay treatment of acute pericarditis is a high-dose aspirin and NSAIDs, other options include colchicines. A patient who has contraindications or failed to respond to first-line therapy may get benefit from corticosteroid. Using corticosteroid and NSAIDs could worsen the general condition of COVID-19 patients, which has created a management dilemma due to the concerns of the safety of using high-dose aspirin safety in these patients. 8 To date, there is no convincing evidence for or against the use of high-dose aspirin in Covid-19 patients.7 The matters were mainly regarding the use of ibuprofen and there is no compelling evidence available connecting worsening of COVID-19 patients status with aspirin or other NSAIDs. To navigate this uncertainty, the Centre for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA) supported the use of NSAIDs when clinically indicated. Dabbagh et al. reported the successful use of corticosteroids and colchicine combination in a patient with cardiac tamponade and COVID-19. 3
Predictors of poor prognosis in acute pericarditis include the following, fever more than 38, large pericardial effusion, subacute onset, cardiac tamponade and lack of response to NSAID or aspirin after at least one week of therapy. Therefore, the presence of fever of 38.1 C in this patient represents one of the poor prognostic features in this attack of pericarditis.