The risk of adverse cardiovascular complications following covid-19 vaccination

Abstract

The current coronavirus disease 2019 (COVID-19) pandemic has urged the scientific
community internationally to find answers in terms of therapeutics and vaccines to control SARS-CoV-2. SARS-CoV-2 is the 7th member of the human coronavirus (CoV) family to be implicated in this zoonotic outbreak. With the global popularity of immunization against COVID-19, reports of vaccine-related adverse events are rapidly growing. Local pain at the injection site is the most prevalent occurrence, as are unusual symptoms such as fever, headache, myalgia, and overall discomfort. Those with COVID-19 and pre-existing cardiovascular disorders (CVDs) are at an increased likelihood of severe morbidity and fatality, and the condition has been related to a number of both direct and indirect CVDs outcomes. As a result of acute coronary syndrome, COVID-19 produces CVDs such as arrhythmias, cardiac arrest, cardiogenic shock, myocarditis, stress-cardiomyopathy, and acute myocardial damage (AMD). Because of underlying chronic comorbidities or impaired immune systems, older persons and adolescents should be particularly cautious about vaccine-related CVDs.

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Introduction
India’s Central Drugs Standard Control Organization (CDSCO)
had given restricted emergency use authorization to seven COVID-19
vaccines; the Oxford-AstraZeneca adenovirus-vectored recombinant
vaccine-AZD1222 and Covishield (ChAdOx1 nCoV-19), whole-
virion inactivated coronavirus vaccine-Covaxin (BBV152) in January
2021, recombinant adenovirus-vectored vaccine-Sputnik V (Gam-
COVID-Vac) in April 2021, Moderna’s mRNA-1273 vaccine (June
2021), Zydus Cadila’s DNA vaccine-ZyCov-D in August 2021 and
Janssen’s Ad26.COV2.S (August 2021). All these vaccines were
rolled out to be given in two doses for optimum efcacy except
Janssen’s Ad26.- COV2.S and ZyCov-D that required one and three
doses, respectively.1,2
Concerned about a pandemic of the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), India has begun immunization
in 2021. With the increased popularity of vaccination, there has been
an increase in reports of various types of adverse effects, particularly
the occurrence of CVDs, which should be monitored.3 Currently,
mRNA, viral vectors, virus-like particles, polypeptides, recombinant
proteins, attenuated live viruses, and inactivated viruses are among
the COVID-19 vaccines that have been licensed for emergency
use or are being studied internationally.4 The mRNA vaccine is the
most concerning of these since it has been observed to elicit local
allergic responses at the injection site as well as unusual symptoms
such as fever, headache, myalgia, and overall discomfort in around
60% of patients following the second inoculation.5 Pzer-BioNTech
(BNT162b1) and Moderna COVID-19 vaccines (mRNA-1273) are
two of the most frequently used mRNA vaccines in the world, allowing
RNA transport into host cells and production of the SARS-CoV-2
S antigen. To defend against COVID-19, the vaccinations provoke
an immune response and create antibodies specic to the SARS-
CoV-2 virus.6 Because of their high potency, the potential for quick
development, and cost-effective manufacture, mRNA-based vaccines
offer several benets over traditional vaccinations. They aggressively
activate B cell responses and stimulate cytokine release by stimulating
CD8+ and CD4+ T cells.7 However, the physiochemical features
of mRNA may impact its cellular transport and organ distribution,
which produces mild to moderate local and systemic symptoms in
the majority of vaccinated patients, casting a shadow on mRNA
vaccine safety and dependability.8 The majority of the symptoms may
be attributed to the vaccine-induced in vivo overproduction of type I
interferons and cytokines.9
Currently, the most extensively utilized COVID-19 vaccines
in India, ChAdOx1 nCoV-19 and BBV152, are inactivated viral
vaccines that stimulate an immune response against SARS-Cov-2 fast
and efciently. Furthermore, they may elicit a robust inammatory
response, leading to serious adverse CVDs.10 Inactivated viruses
are appealing because they can display numerous viral proteins for
immune detection. Other proteins, in addition to the S protein, might
function as possible antigens for SARS-Cov-2, including the N
protein, M protein, non-structural proteins, and accessory proteins.6
This raises the question of whether these insignicant antigens may
change the immune system. Furthermore, more focus should be given
to the antibody-dependent enhancement (ADE) of SARS-CoV-2
infection, because many severe patients with COVID-19 frequently
exhibited more robust immunoglobulin G (IgG) responses and higher
antibody titers, both of which are associated with poorer clinical
outcomes.11,12
It is presently unknown if these vaccinations generate aberrant
antibody responses, and further study is needed to address the possible
harm associated with SARS-CoV-2 vaccines. Cardiometabolic
disorders such as hypertension, atherosclerosis, heart failure, and
diabetes are common problems in COVID-19 patients.13-15 Populations
with prior underlying disorders are at a higher risk of SARS-CoV-2
infection and a worse clinical outcome.16-18 Vaccine immunity is known
to be inuenced by age. Following the rst vaccination dosage, serum
neutralization and levels of binding IgG or immunoglobulin A (IgA)
were lower in older groups, with a signicant drop in persons over
the age of 80. Serum from participants over the age of 80 had reduced
neutralization power against the B.1.1.7 (Alpha), B.1.351 (Beta), and
P.1. (Gamma) variants and was more likely to lack any neutralization
after the rst dose.19 After the rst treatment, the frequency of SARS-
CoV-2 spike-specic memory B cells fell in non-responders, and CD4
T cell production of interferon- and interleukin-2 was repressed in
Pharm Pharmacol Int J. 2023;11(1):10‒13. 10
©2023 Alam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work non-commercially.
The risk of adverse cardiovascular complications
following covid-19 vaccination
Volume 11 Issue 1 - 2023
Md Tauque Alam, Rahul Sharma, Md Sadique
Hussain
School of Pharmaceutical of Sciences, Jaipur National University,
India
Correspondence: Md Sadique Hussain, School of
Pharmaceutical Sciences, Jaipur National University
Jaipur, 302017, Rajasthan, India,
Email
Received: December 04, 2022 | Published: January 10, 2023
Abstract
The current coronavirus disease 2019 (COVID-19) pandemic has urged the scientic
community internationally to nd answers in terms of therapeutics and vaccines to control
SARS-CoV-2. SARS-CoV-2 is the 7th member of the human coronavirus (CoV) family
to be implicated in this zoonotic outbreak. With the global popularity of immunization
against COVID-19, reports of vaccine-related adverse events are rapidly growing. Local
pain at the injection site is the most prevalent occurrence, as are unusual symptoms such as
fever, headache, myalgia, and overall discomfort. Those with COVID-19 and pre-existing
cardiovascular disorders (CVDs) are at an increased likelihood of severe morbidity and
fatality, and the condition has been related to a number of both direct and indirect CVDs
outcomes. As a result of acute coronary syndrome, COVID-19 produces CVDs such as
arrhythmias, cardiac arrest, cardiogenic shock, myocarditis, stress-cardiomyopathy,
and acute myocardial damage (AMD). Because of underlying chronic comorbidities or
impaired immune systems, older persons and adolescents should be particularly cautious
about vaccine-related CVDs.
Keywords: COVID, coronavirus, cardiovascular disorders, adverse effects, vaccine
Pharmacy & Pharmacology International Journal
Mini Review Open Access

The risk of adverse cardiovascular complications following covid-19 vaccination 11
Copyright:
©2023 Alam et al.
Citation: Alam MT, Sharma R, Hussain MS. The risk of adverse cardiovascular complications following covid-19 vaccination. Pharm Pharmacol Int J.
2023;11(1):10‒13. DOI: 10.15406/ppij.2023.11.00395
older participants. 15 Furthermore, 9.7% of patients had COVID-19
in addition to diabetes.20 The expression of the ACE2 receptor (total
and glycosylated form) was elevated in diabetic cardiomyocytes,
increasing vulnerability to SARS-CoV-2 inltration by facilitating
viral cellular entrance.21 Furthermore, hyperglycemia reduced the
efcacy of tocilizumab therapy in both diabetic and non-diabetic
individuals.22 Early glycemic management may be an appropriate
treatment approach to improve outcomes in COVID-19 hospitalised
patients with or without diabetes. Diabetes and hyperglycemia
may impair responsiveness to anti-inammatory and anti-viral
medications. However, it is uncertain whether there is a comparable
issue with the diabetes vaccine. Specic approaches are needed to
increase vaccination response in the elderly and diabetic groups.23
There have been reports of serious adverse effects associated with
the COVID-19 vaccination, including neuritis, facial nerve palsy,
myocarditis, and thrombosis.24-26 Myocarditis is an uncommon but
signicant consequence of vaccination that is usually self-limiting
but can be fatal.27 Recently, reports of vaccination-related myocarditis
(Table 1) have largely been linked to the mRNA vaccine, which
caused severe chest discomfort immediately after inoculation and
was associated with elevated biomarkers for myocardial damage.28-30
Cardiac magnetic resonance imaging reveals classic myocarditis signs
including regional dysfunction, late gadolinium enhancement, and
higher native T1 and T2 levels.31 Thrombosis with thrombocytopenia
syndrome (TTS) is a signicant vaccination-related event that
primarily affects women within 2 weeks after receiving the Chadox1
nCoV-19 or Ad26 vaccine.32
Table 1 Summary of cardiovascular adverse reactions and incidence rates after COVID-19 vaccination
Authors Data sources Vaccines names Vaccine types Cardiovascular adverse reactions
Abu Mouch et al.24 Case report BNT162b2 vaccine mRNA 5 patients presented myocarditis after the
second and 1 after the rst dose of the vaccine
Chamling et al.28 EudraVigilance Pzer-BioNTech and ChAdOx1
nCoV-19 vaccine
mRNA/adenovirus
vectored
309 (18–64 years old) reported cases of
myocarditis associated with Pzer-BioNTech,
19 (65–85 years old) with ChAdOx1 nCoV-19
vaccine
Deb et al.29 VAERS and CDC
website mRNA-1273 mRNA 37 vaccine recipients developed myocarditis
related to mRNA-1273 vaccine
Kim et al.31 Case series 2 received mRNA-1273, and 2
received BNT162b2 mRNA
7 patients with acute myocarditis over 3-months
which 4 occurred within 5 days of COVID-19
vaccination
Lai et al.32 EudraVigilance ChAdOx1 nCoV-19 and Ad26.
COV2.S vaccines
adenovirus
vectored
169 cases of CVST and 53 cases of splanchnic
vein thrombosis following ChAdOx1 nCoV-19
vaccination out of 34 million people
Lai et al.32 VAERS Ad26.COV2.S adenovirus
vectored
6 cases of CVST with thrombocytopenia
following the administration of 6.86 million doses
Sessa et al.33 VAERS Pzer-BioNTech or mRNA-1273
vaccine mRNA 68 thromboembolic events out of 13.6 million
younger women
Welsh et al.34 VAERS Pzer-BioNTech or mRNA-1273
vaccine mRNA
15 cases of thrombocytopenia were identied
among 18,841,309 doses of Pzer-BioNTech
Vaccine and 13 cases among 16,260,102 doses of
mRNA-1273 vaccine
Other vaccinations appear to be safe, with no abnormally high
rates of thromboembolic events or thrombocytopenia reported.33,34
In severe COVID-19 individuals, impaired type I interferon (IFN)
activity was detected, which is characterized by a lack of IFN- and
low IFN- production, as well as enhanced inammatory responses.35
Excessive immunological responses generated by vaccinations may
increase myocardial ischemia and plaque development, resulting in
myocardial damage and, in extreme cases, plaque rupture and acute
myocardial infarction.36 Because teenagers’ immune systems are
still developing, immunization may result in secondary myocarditis,
cardiomyopathy, arrhythmia, and heart failure.37 A recent phase I/
II clinical research found that the CoronaVac vaccination was safe,
tolerable, and immunogenic in children and adolescents aged 3-17
years, with injection site discomfort being the most prevalent adverse
event.38 Long-term immunogenicity and safety, on the other hand, were
not available and must be carefully monitored. Furthermore, stressors
such as anxiousness during immunization may cause hypertension,
myocardial ischemia, and arrhythmias.39
Guidelines or recommendations on the use of COVID-19
vaccinations and the avoidance of adverse effects are becoming
more common. According to the Centers for Disease Control and
Prevention, vaccination sites should:40,41
a) Ensure that necessary supplies, particularly sufcient quantities
of epinephrine in prelled syringes, are available to manage
anaphylaxis;
b) Screen potential vaccine recipients to identify people with
contraindications and precautions, particularly those with CV
metabolic comorbidities;
c) Implement recommended post-vaccination observation periods,
either 15 or 30 minutes; and
d) Ensuring that healthcare personnel can identify the signs and
symptoms of anaphylaxis and other life-threatening reactions as
early as possible.
These restrictions should be vigorously enforced, particularly in
rural settlements. Patients should seek emergency medical attention
if they have signs or symptoms such as unrelenting chest tightness or
palpitations during or after the observation period.42 Clinicians should
be on the lookout for vaccine-related CV complications such as
myocarditis. Emergency electrocardiograms and myocardial damage
biomarker tests are required, as does echocardiography if available.
Consultation with hematology is recommended when TTS is highly
suspected or proven. Intravenous immunoglobulin and anticoagulation

The risk of adverse cardiovascular complications following covid-19 vaccination 12
Copyright:
©2023 Alam et al.
Citation: Alam MT, Sharma R, Hussain MS. The risk of adverse cardiovascular complications following covid-19 vaccination. Pharm Pharmacol Int J.
2023;11(1):10‒13. DOI: 10.15406/ppij.2023.11.00395
may be used, although heparin-based medicines and platelet
transfusion should be avoided.43 Finally, it is important to alleviate
anxiousness and aid individuals in performing health management in
their everyday lives, avoiding extreme variations in blood pressure or
blood glucose, and emphasizing primary prevention of CVDs during
immunization. Furthermore, infrequent and substantial side events
following COVID-19 immunization emphasize the signicance of
building an effective vaccine safety monitoring system. National
regulatory bodies should develop formal trans-regional cooperation
to encourage vaccination safety data exchange.44
Acknowledgments
None.
Conicts of interest
The authors declared no conict of interest.
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