Stage III Hypertension in Patients After mRNA-Based SARS-CoV-2 Vaccination

HomeHypertensionVol. 77, No. 6Stage III Hypertension in Patients After mRNA-Based SARS-CoV-2 Vaccination Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBStage III Hypertension in Patients After mRNA-Based SARS-CoV-2 Vaccination Sylvain Meylan, Françoise Livio, Maryline Foerster, Patrick James Genoud, François Marguet, Gregoire Wuerzner and on behalf of the CHUV COVID Vaccination Center Sylvain MeylanSylvain Meylan Correspondence to: Sylvain Meylan, Infectious Diseases Service, Departement of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, BH09-788, 1011 Lausanne, Switzerland. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6319-2423 Department of Medicine, Infectious Diseases Service, University Hospital Lausanne and University of Lausanne, Switzerland (S.M.). , Françoise LivioFrançoise Livio Service of Clinical Pharmacology, Department of Laboratories (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland. , Maryline FoersterMaryline Foerster Emergency Department (M.F.), University Hospital of Lausanne, Switzerland. , Patrick James GenoudPatrick James Genoud Nursing Directorate (P.J.G., F.M.), University Hospital of Lausanne, Switzerland. , François MarguetFrançois Marguet Nursing Directorate (P.J.G., F.M.), University Hospital of Lausanne, Switzerland. , Gregoire WuerznerGregoire Wuerzner https://orcid.org/0000-0002-6424-7630 Department of Medicine, Service of Nephrology and Hypertension (G.W.), Lausanne University Hospital and University of Lausanne, Switzerland. and on behalf of the CHUV COVID Vaccination Center Originally published25 Mar 2021https://doi.org/10.1161/HYPERTENSIONAHA.121.17316Hypertension. 2021;77:e56–e57Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 25, 2021: Ahead of Print On January 11, the vaccination center in Lausanne—a city of 140 000 inhabitants in western Switzerland—started the coronavirus disease 2019 (COVID-19) vaccination with mRNA-based vaccines. As of February 9, 13 296 vaccine doses were administered with 12 349 patients receiving the first dose (10501 Pfizer/BioNTech, 1848 Moderna) and 947 receiving a second dose (945 Pfizer/BioNTech, 2 Moderna). The center offers vital signs monitoring for any patient reporting symptoms compatible with a serious adverse event such as suspicion of anaphylactic reaction, malaise, shortness of breath, or pain (eg, headache and chest pain). Any adverse event is medically monitored and those which are serious or unexpected are reported to Swissmedic—the Swiss Agency for Therapeutic Products.We report a case series of 9 patients with stage III hypertension documented within minutes of vaccination during the first 30 days, of which 8 were symptomatic. Inclusion criteria for monitoring are detailed in Table. Vital signs were measured with an oscillometric manometer (Omron Healthcare Europe; a HEM 907-E7) with at least 3 sets of separate values at 5-minute intervals. Median age was 73 (IQR, 22) years and sex distribution was 7 women for 2 men. Eight of 9 patients had a history of arterial hypertension with most patients on antihypertensive therapy. All but one patient received the Pfizer/BioNTech (BNT162b2) vaccine. Of note, the Moderna (mRNA-1273) vaccine was only introduced in late January in Switzerland. One of the patients (n=3) reported a cerebral aneurysm that was coiled within the last year, with a targeted SBP <140 mm Hg.1 Due to developing headache, the patient underwent imaging with no sign of intracranial hemorrhage. Patient No. 4 did not have associated ECG changes or an increase in hs-troponins. Importantly, all patients recovered but required at most several hours of monitoring at our tertiary center's emergency department.Table. Patient characteristics.PatientAge, yHistory of HTTreatmentSexSBP/DBP, mm HgHeart rate, bpmAssociated symptom(s)VaccineDoseOutcome154Yes*YesM170/11188MalaiseBNT162b21Transfer to ER with amlodipine287YesYesF181/9072MalaiseBNT162b21Transfer to ER365Yes†YesF182/10173HeadacheBNT162b21Transfer to ER. Imaging reveals no intracranial bleeding, nifedipine.470YesYesF177/8873Chest painBNT162b21Transfer to ER, no argument for ACS. Spontaneous resolution.588Yes‡NoM168/11572DiaphoresisBNT162b21Spontaneous resolution, no transfer to ER.677YesNAF200/10080AnxietyBNT162b21Refused monitoring and workup.773YesYesF180/10682Tingling in mouthBNT162b21Self-medication with nifedipine. Resolution of symptoms, normalization of blood pressure.855NoNoF183/9865Malaise, headacheBNT162b21Transfer to ER, amlodipine single dose, monitoring and transition to outpatient care.987YesYesF220/10280Swelling at injection sitemRNA-12731Transfer to ER, candesartan and isosorbide dinitrate, monitoring and transition to outpatient care.ACS indicates acute coronary syndrome; DBP, diastolic blood pressure; ER, emergency room; F, female; HT, arterial hypertension; M, male; NA, not available; and SBP, systolic blood pressure.* Diagnosed 2 mo prior.† History of coiled vascular aneurysm with requirement to maintain SBP under 140 mm Hg.‡ White coat hypertension.Due to the patient high throughput in our vaccination center, we do not have prevaccination BP values. However, 8 of 9 patients reported otherwise well controlled hypertension. Our case series suggests that a fraction of hypertensive patients may react with symptomatically significant increases in both systolic and diastolic blood pressure. A stress response is likely in view of the public debate, in addition to pain response and white coat effect—the latter being associated with age and female sex.2 However, the relatively low heart rate (median, 73 bpm) may soften this hypothesis. Alternative mechanisms could theoretically include hypertension to components of the vaccines such as polyethylenglycol, although this seems unlikely due to the presumably low dosage and as patients reacted within minutes of the injection. As tromethamine is only contained in the MRNA-1273 vaccine, its causative role is ruled out. An interaction between the S-protein and angiotensin converting enzyme 2 also seems highly unlikely as patients reacted within minutes of the injection, not leaving time for mRNA cellular uptake, translation, and S-protein presentation at the membrane of macrophages and dendritic cells.The rollout of vaccines in many parts of the world focuses on the vulnerable populations (>75 years of age, risk factor groups including hypertension). The mRNA vaccines have received intense scrutiny for immediate hypersensitivity reactions in the wake of an initial report signaling 21 cases of anaphylaxis.3 Hypertension, on the contrary, has not been mentioned explicitly as an adverse event in both safety/immunogenicity trials. However, both phase I/II and III clinical trials for the mRNA vaccines included predominantly younger populations with a mean and median age of 31 and 52 years for the BNT162b2 vaccine4 and 31 and 51 for the mRNA-1273 vaccine.5 Although more data are needed to understand the extent and the mechanism of hypertension after mRNA-based vaccination, our data indicate that in elderly patients with a history of hypertension or significant prior cardiovascular comorbidities, prevaccination control of blood pressure and post-vaccination monitoring, including symptom screening, may be warranted.AcknowledgmentsWe thank all collaborators of the coronavirus disease 2019 (COVID-19) vaccination center in Lausanne. Special thanks to Thierry Calandra for insightful comments.Sources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page e57.Correspondence to: Sylvain Meylan, Infectious Diseases Service, Departement of Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, BH09-788, 1011 Lausanne, Switzerland. Email [email protected]. Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SC, et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention; American Heart Association; American Stroke Association. Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2015; 46:2368–2400. doi: 10.1161/STR.0000000000000070LinkGoogle Scholar2. Thomas O, Shipman KE, Day K, Thomas M, Martin U, Dasgupta I. Prevalence and determinants of white coat effect in a large UK hypertension clinic population.J Hum Hypertens. 2016; 30:386–391. doi: 10.1038/jhh.2015.95CrossrefMedlineGoogle Scholar3. CDC COVID-19 Response Team; Food and Drug Administration. Allergic reactions including anaphylaxis after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine — United States, December 14–23, 2020.Morbidity Mortal Wkly Rep. 2021; 70:46–51. doi: 10.15585/mmwr.mm7002e1CrossrefMedlineGoogle Scholar4. Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, et al; C4591001 Clinical Trial Group. Safety and efficacy of the BNT162b2 mRNA covid-19 vaccine.N Engl J Med. 2020; 383:2603–2615. doi: 10.1056/NEJMoa2034577CrossrefMedlineGoogle Scholar5. Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, Diemert D, Spector SA, Rouphael N, Creech CB, et al; COVE Study Group. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine.N Engl J Med. 2021; 384:403–416. doi: 10.1056/NEJMoa2035389CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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