Palpitations and shortness of breath while waiting for COVID-19 booster vaccine

• Immunity significantly wanes over six months after receiving the Pfizer–BioNTech COVID-19 vaccine.
• Immunity significantly improves after a third booster dose of the Pfizer–BioNTech COVID-19 vaccine.
• A routine six-month booster dose should be part of the national COVID-19 vaccination strategy.

He had stoically carried on at work despite being frightened he might “bring the virus home” to his family

A 55-year-old friend and colleague – an experienced physician at your local hospital – presents to you complaining of an increasing tendency to intermittently feel very short of breath during the daytime.

These episodes often occur in his office after his “morning” ward round, which currently takes five to seven hours to complete, when previously it was four hours on a busy day.

He explains that the delays are, in part, due to the personal protective equipment (PPE) he has to don and doff during his ward rounds for the highrisk patients.

He is also waking at night with a fast, regular, “pounding” heartbeat and seemingly inexplicable episodes of “complete panic and agitation”.

In the last two weeks, he has needed to wake his wife on two occasions, so she could comfort him when he was uncontrollably agitated. He is completely perplexed as to how this could happen to him.

Your patient is a well-known, gentle specialist physician. He is renowned for his care of patients and their families. He is well known in the hospital for his support of nursing and ancillary staff, as well as the time taken on his rounds to teach the junior doctors in his team.

Since the onset of the COVID-19 pandemic, he has been busier than usual, both at the hospital and at his private rooms, where he spends one-quarter of his time. In March 2020, he and his colleagues, all in their 50s, calculated they were at approximately 2–3 per cent risk of death should they catch severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of coronavirus disease 2019 (COVID-19).

He had worked through the dark days of the pandemic, including 28 February 2020 when New Zealand confirmed its first case of COVID-19. He had experienced the lack of full PPE and the uncertainty of COVID-19 as it spread through patients during the level 4 lockdown from 26 March 2020. As with all healthcare workers, he had stoically carried on at work despite being frightened he might “bring the virus home” to his family.

While wanting to be a supporter of the national COVID-19 strategy, he is increasingly critical of the Government and Ministry of Health response, which he feels has been slow and poorly delivered. The Pfizer–BioNTech COVID-19 vaccination programme was rolled out in the UK from December 2020, whereas the first shipment of the vaccine – some 60,000 doses – did not arrive in New Zealand until 15 February.

He had waited in line until after the DHB board chairman received his first vaccination. Your patient then received his first dose in March and the second in April. However, he is very aware that a booster dose is needed six months after the second dose, and he is now experiencing the same stresses he felt in 2020, as it is now more than seven months since his second dose.

He is usually fit and well, and he is happily married with three healthy children. His past history is only of mild hypertension, which is treated with candesartan 16mg daily. He has never smoked and previously drank alcohol in a modest way, although admits to heavier drinking over the last few months.

On examination, he is a pleasant, middle-aged man, although a little agitated as he discusses his problems. His blood pressure is 140/90mmHg, and he has a regular pulse at 90 beats per minute, with normal heart sounds. His chest is clear. A resting electrocardiogram is taken.

1. What does the ECG show?
2. What is the likely diagnosis?
3. What would be your initial management plan?
4. What is the evidence of waning effectiveness after the second dose of the Pfizer–BioNTech COVID-19 vaccine?
5. What is the evidence of effectiveness of a booster dose of the Pfizer–BioNTech vaccine?
6. How do you help your patient from here?

1. The ECG shows sinus rhythm, a rate of 85 beats per minute, a normal axis and a partial right bundle branch block pattern. It is normal.

2. The clinical history is important – your patient’s symptoms are clearly related to the persistent stress he is experiencing. Some of the symptoms might suggest a post-traumatic stress syndrome.

3. You have already performed a careful history, clinical examination and ECG, which are all normal. Your main management strategy is to sympathise with his situation, explaining that he is certainly not alone in the community and hospital workforce, where these symptoms are increasingly experienced.

You do arrange for some routine blood tests to be performed: a full blood count, C-reactive protein, creatinine and electrolytes, liver function tests, thyroid function tests, serum glucose level and lipid profile. You also arrange a follow-up visit next week to review the results, although you both know it is to reassess and re-counsel your patient.

You suggest some time off work, but your patient advises that others in the hospital are “worse than me”, and he feels it necessary to continue in his role. You advise regular exercise in the sunshine.

4. There is now clear evidence from observational reports in Israel and the US that immunity wanes after receiving the Pfizer–BioNTech COVID-19 vaccine.

A Lancet paper published online on 4 October assessed 3.4 million electronic patient records from a California healthcare provider. For fully vaccinated individuals, the effectiveness against SARS-CoV-2 infections declined from 88 per cent (95 per cent confidence interval 86–89) during the first month after full vaccination to 47 per cent (95 per cent CI 43–51) after five months.¹

5. A Lancet paper published online on 29 October matched 728,321 Israeli individuals who had received a third dose of the Pfizer–BioNTech COVID-19 vaccine with the same number of controls who had received only two doses at least five months before.²

Compared with receiving two doses, vaccine effectiveness at least seven days after receipt of the third dose was estimated to be 93 per cent for hospital admission (231 events for two doses versus 29 events for three doses; 95 per cent CI 59–97), 92 per cent for severe disease (157 versus 17 events; 95 per cent CI 82–97), and 81 per cent for COVID-related death (44 versus seven events; 95 per cent CI 59–97).²

6. You discuss and comment on the irony that, except for the anti-vaccine population, the most-at-risk people in the community (nurses, doctors and other healthcare staff), who are now going to regularly meet COVID-positive patients, are among the least protected in the country.

You confirm your patient’s diagnosis that he is “stressed out”. You agree to meet every two weeks until he is better, and to swap COVID-19 cartoons to allow laughter to return to both of your lives. He appreciates the opinion and support you are able to give him.

Chris Ellis is a consultant cardiologist at The Heart Group and Mercy Hospital, Auckland

Details have been changed to protect patient confidentiality

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