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.