Cardiovascular involvement in Epstein–Barr virus infection, 2023, Xinying Chen et al

Cardiovascular involvement is an uncommon but severe complication of Epstein–Barr virus (EBV) infection caused by direct damage and immune injury. Recently, it has drawn increasing attention due to its dismal prognosis. It can manifest in various ways, including coronary artery dilation (CAD), coronary artery aneurysm (CAA), myocarditis, arrhythmias, and heart failure, among others. If not treated promptly, cardiovascular damage can progress over time and even lead to death, which poses a challenge to clinicians.Early diagnosis and treatment can improve the prognosis and reduce mortality.

However, there is a lack of reliable large-scale data and evidence-based guidance for the management of cardiovascular damage. Consequently, in this review, we attempt to synthesize the present knowledge of cardiovascular damage associated with EBV and to provide an overview of the pathogenesis, classification, treatment, and prognosis, which may enhance the recognition of cardiovascular complications related to EBV and may be valuable to their clinical management.

https://www.frontiersin.org/articles/10.3389/fimmu.2023.1188330/full

 

Treatment
The treatment and management of cardiovascular involvement associated with EBV infection remain challenging. According to the existing literature, CALs are more common in CAEBV and EBV-HLH, while myocarditis occurs more often in AEBV. As mentioned previously, EBV-related cardiovascular involvement is classified into direct and immune injury. Consequently, its treatment mainly includes three parts: antiviral therapy, anti-inflammatory therapy, and the management of cardiovascular complications.

Antiviral therapy, such as acyclovir and ganciclovir, can decrease viral replication during the acute phase, but with uncertain efficacy in patients with CAEBV and EBV-HLH. Inflammation can be reduced or blocked by glucocorticoids and other immunosuppressants, but complete remission of CAEBV and EBV-HLH requires drug chemotherapy or hematopoietic stem cell transplantation (SCT).

As for specific cardiovascular complications, different manifestations should be managed according to relevant guidelines. The treatment of CALs mainly involves antiplatelet therapy, anticoagulant therapy, and medications that inhibiting or reverse remodeling. If there is thrombosis and/or embolism, long-term use of antiplatelet and anticoagulant drugs should be considered (61). Aspirin is usually the go-to anticoagulant for medical therapy, and clopidogrel is an alternative or combination.

Patients with large CAA often require a combination of antiplatelet and anticoagulant drugs in order to prevent thrombotic events (46).

Clinical studies have not been able to support the use of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) medications as standard treatments for EBV-associated CAI. In fact, there is no evidence suggesting potential benefits to those who receive these medications. When dealing with acute myocarditis, it is important to closely observe cardiovascular health and heart rhythm and provide the necessary support, similar to the approach taken with cases of acute heart failure (62). If there is low cardiac output, immediate steps, such as administering inotropic medications and vasopressors, must be taken to rectify the condition (62). Furthermore, if a dangerous irregular heart rhythm arises, implanting a temporary pacemaker should be taken into consideration as soon as possible