Cardiovascular Implications of COVID-19 in Children and Adolescents
The new coronavirus pandemic has been responsible for more than 2 million deaths worldwide and over 400,000 deaths in the United States. In the U.S., children make up about 12% of total cases (2 million children infected so far), with a pediatric hospitalization rate of 1.3% and mortality rate of 0.01%.
Despite this relatively low death rate, there has been increasing recognition of serious medical complications, including multisystem inflammatory syndrome in children, or MIS-C, and long-term heart damage.
MIS-C is a multisystem inflammatory response to COVID-19 that can involve the heart, lungs, kidneys, liver and brain. It can cause life-threatening shock and respiratory failure, and has a mortality rate of just under 2% — over 100 times that of COVID-19 disease itself in the pediatric population. Originally thought to be a variant of Kawasaki disease, the clinical presentation of MIS-C can include prolonged fever, headache, sore throat, conjunctivitis, oral mucosal changes, abdominal pain, vomiting, diarrhea, rash, swollen hands or feet, and elevated inflammatory markers. Cardiovascular manifestations of MIS-C mimic acute myocarditis and include abnormal cardiac enzymes (troponin levels) ventricular dysfunction, arrhythmias and cardiogenic shock. Children suspected of having MIS-C should be evaluated in the pediatric emergency department, and, if they meet criteria, should be admitted to the hospital or intensive care unit.
There is also increasing evidence for widespread myocardial fibrosis even after a mild bout of COVID-19, which can increase the risk of arrhythmia or sudden death during the return to physical activity. In healthy college-age athletes, this can be seen in approximately 10-30% of patients; in some groups of older adults it is seen in 60-80%. For this reason, current guidelines recommend stratifying adolescent athletes who have had COVID-19 into three categories: 1) Low-risk individuals who were asymptomatic or had symptoms for less than three days; they can return to sports without further evaluation after being symptom-free for 14 days; 2) Moderate-risk individuals who had prolonged fevers or symptoms but were not hospitalized; in many cases, they can gradually return to activity after monitoring symptoms for 14 days, often with either no testing or a simple electrocardiogram and/or echocardiogram; 3) High-risk individuals who were hospitalized or had abnormal cardiac testing during their acute illness; they typically require rest for three to six months and a cardiology evaluation with extensive testing (i.e., a combination of an echocardiogram, Holter monitor, stress test and cardiac MRI) prior to a gradual return to exercise.
Our pediatric cardiologists at the UF Health Congenital Heart Center are ready to assist with all aspects of cardiovascular care during and after COVID-19 infection. Please call if we can help, or to discuss any individual case.