Eckart RE, Atwood JE, Grabenstein JD, Love SS, Riddle JR, Arness MK, Engler RJ

1. Incidence and Follow-Up of Inflammatory Cardiac Complications after Smallpox Vaccination in a Large Cohort of Healthy Vaccinees Eckart RE, Atwood JE, Grabenstein JD, Love SS, Riddle JR, Arness MK, Engler RJ for the Department of Defense Smallpox Vaccination Clinical Evaluation Team

2. Methods • Population: 626,000 smallpox vaccinees, Dec 02 thru May 04 • Case Identification • DMSS, active solicitation, publications (MMWR, JAMA, JACC), VAERS • 71 cases identified, 69 cases with data made available for review > 60 days since diagnosis used as cohort for this presentation • Data collated and centralized by Vaccine Healthcare Centers (VHC) • Clinical Follow-up Protocol • Guidelines for follow-up developed through working groups facilitated by VHC Network and Military Vaccine Agency • Distributed to providers June 9, 2003 • Clinical evaluation, labs, ECG, echo, and stress test at 6-12 wks (+ 6-12 mon) • Patients with persistent symptoms could be transferred to regional hospital for further evaluation • http://www.smallpox.mil/media/pdf/algorhythm.pdf

3. Case Demographics

4. Follow-up • Data available on 66 (96%) of 69 cases • Mean of 31±16 weeks after presentation • Two patients self-reported as healthy but voluntarily separated from military service and declined to return for follow-up • One patient died during hospitalization • Unlike other cases, had normal cardiac enzymes 15 and 28 days post-vaccination, prolonged pulmonary condition, elevated enzymes 32 post vaccination

5. Electrocardiography • Initial tracing available for review in 62/66 (94%) • Identifiable abnormality in 46 (70%) of 66 • ST-segment abnormality in 40 patients • 35 (56.5%) pathologic ST-segment elevation • 5 ( 8.1%) had normal-variant early repolarization • T-wave abnormality in 11 (18%) • 46 (70%) had follow-up data available for review • 14-362 days (median 108) from initial presentation • Normalization of pathologic ST-segment elevation and T-wave inversions in all 46 patients

6. Electrocardiography

7. Electrocardiography • Ventricular repolarization heterogeneity has been associated with risk of sudden death, and normalization has been associated with decreased risk • Interlead QTc-d, at baseline vs. follow-up 67±27 vs. 22±23 msec, p<0.001 (95% CI 35-59 msec) • Proven stabilization of ventricular repolarization using QTc-d as a surrogate measure. • In other cardiac pathology, normalization of repolarization may be associated with decreased inflammation. • All follow-up ECGs had normal parameters for ventricular repolarization ~40 msec

8. Echocardiography • 58 (84%) with echo during acute illness • Follow-up in 43 patients • 11-362 days (median 103 days) after diagnosis • LVEF 61±3% (range 55-75%) • No evidence of ventricular dilatation, diastolic dysfunction, regional wall motion abnormality, or pericardial effusion

12. Functional Assessment • Treadmill testing using Bruce protocol • 43 patients at 18-411 days (median 103 days) • Exercise duration 12.4±1.9 min (range 9.0-17.0 min) • Maximum heart rate 184±11 bpm (95.9±6.2% age-adjusted maximum predicted heart rate) • Rate-pressure product of 31,573±5,130 • No ECG abnormalities and no cardiac symptoms were provoked

15. Persistently Symptomatic Patients

17. Limitations • Data for recovery recorded as time of documentation • Data presented are “worst-case” scenario • Alternative etiologies for persistence of symptoms? • “Get better to get deployed” • Pre-existing migraine disorder in a patient with persistent headache • “Fatigue” despite improved objective functional assessment • Need for more objective data about subjective symptoms • Reported symptoms not challenged • VHC created structured questionnaire for annual follow-up using validated scales to collect subjective information The views expressed are those of the presenting author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

19. Conclusions • Post-vaccinial myopericarditis should be considered in patients with chest pain 30 days following smallpox vaccination • ECG, echocardiography, and functional status shown to return to normal within a few months after onset of illness • Normal findings on all patients studied, after previously recommended 4 to 6 week period of recovery • 24% of patients had persisting subjective complaints • 40% of these are not referable to cardiac disease • Those with atypical, persistent chest discomfort had no objective functional limitation and have normal myocardial function

20. Incidence and Follow-Up of Inflammatory Cardiac Complications after Smallpox Vaccination in a Large Cohort of Healthy Vaccinees Eckart RE, Atwood JE, Grabenstein JD, Love SS, Riddle JR, Arness MK, Engler RJ for the Department of Defense Smallpox Vaccination Clinical Evaluation Team

21. Presentation • All 69 cases presented initially with chest pain • Prodromal symptoms documented in 63 (91.3%) • 35 (56%) fever and chills • 19 (30%) myalgias and/or arthralgias • 27 (43%) headache, “viral syndrome” and fatigue • 9 (14%) no prodromal syndrome until chest pain prompted medical evaluation

22. Week 2 Week 4 Electrocardiography Week 1 Week 10

23. Laboratory Studies • Variable work-up to date • However, no reported abnormalities in various markers of inflammation and injury based on reported individual laboratory parameters • Troponin-I • B-type natriuretic peptide • high sensitivity/ultra-sensitive/“regular” C-reactive protein • Difficulty with standardization of BNP and CRP makes comparison difficult

24. What is a normal EF?

29. Follow-up on Patients with Initially Depressed Ejection Fraction • No change in follow-up exercise capacity, or symptoms.