Cardiovascular Issues After COVID-19 Uncommon for Most Children and Young Adults

By IDSE News Staff

Although cardiovascular (CV) complications do not commonly occur in most children and young adults with COVID-19, some might experience arrhythmia, myocarditis and multisystem inflammatory syndrome in children (MIS-C). Most cases are manageable, according to a new statement from the American Heart Association (Circulation 2022 Apr 11. https://doi.org/10.1161/CIR.0000000000001064).

The AHA issued a scientific statement that details current data on preventing, treating and managing CV complications caused by the SARS-CoV-2 virus in youth. The latest data indicate CV effects are rare in young people in the United States, and for most, they are treatable. Returning to sports and strenuous physical activity after heart symptoms resolve is safe, although additional screening may be considered for youth who experience more severe symptoms; and the best offense is a good defense, so vaccination is a good choice.

The new statement calls for more research, including studies to look at the long-term CV effects of COVID-19 in children and young adults. The group’s extensive research on the latest data found children with congenital heart disease have low rates of infection and complications from SARS-CoV-2, the virus that causes COVID-19 disease. 

“Two years into the pandemic and with vast amounts of research conducted in children with COVID-19, this statement summarizes what we know so far related to COVID-19 in children,” said the chair of the statement writing group Pei-Ni Jone, MD, FAHA, the director of 3D Echocardiography, the Kawasaki Disease Clinic and Quality in Echocardiography at Children’s Hospital Colorado, in Aurora. “We focused on the effects of this virus for those with congenital or other heart disease, as well as the latest data about the potential association of the COVID-19 vaccines with heart complications in children and young adults. While there is a lot we know, this public health emergency needs ongoing research to understand the short- and long-term impacts on children.”

Factors for Differences in Susceptibility

As of Feb. 24, 2022, U.S. children have accounted for 17.6% of total COVID-19 cases and about 0.1% of deaths from the virus, and young adults, ages 18 to 29 years, have accounted for 21.3% of cases and 0.8% of deaths from COVID-19. 
Studies suggest a few factors may help to explain why children may be less susceptible to severe COVID-19 infection: 

• Cells in children’s bodies have fewer receptors to attach to the SARS-CoV-2 virus. 
• Children may have a lower immune response due to a different cytokine response compared with adults. 
• Trained immunity from other vaccines and viral infections may play a protective role. 

Another finding is that having an underlying genetic syndrome, such as trisomy 21, appears to be associated with an increased risk for severe COVID-19.

There are no COVID-19 antiviral therapies specifically for children, but remdesivir and dexamethasone may be appropriate for children in certain age groups. Remdesivir is the only antiviral drug approved by the FDA for the treatment of people 12 years of age and older hospitalized with COVID-19 who have risk factors for severe disease and the need for supplemental oxygen, and it is most effective when given as soon as possible after symptoms begin. Dexamethasone, which has been shown to reduce the risk for death in adults with COVID-19, is suggested for children with more severe disease who require breathing support.

Heart-related complications in children with COVID-19 are uncommon. Case reports of cardiac complications include cardiogenic shock, myocarditis and arrhythmias. Sudden cardiac death, and death following intensive medical and life support treatment, have occurred in children with severe COVID-19 that affected the heart.

During the first year of the pandemic, one of every 3,164 children with SARS-CoV-2 infection developed MIS-C, most often among Black and Hispanic youth.

For children who develop MIS-C, intravenous immune globulin (IVIG) has been administered alone or as dual therapy with infliximab or other immunomodulatory agents. Most children’s hearts recovered well within one to four weeks of MIS-C diagnosis. The risk for long-term complications and death from MIS-C is estimated to be 1.4% to 1.9%.

The panel called for more research into why people from diverse racial or ethnic groups may be disproportionately at risk for MIS-C.

Back in the Game

For children and young adults who have had COVID-19, the return to sports and strenuous physical activity has been an area of targeted research and examination. The latest data suggest those who had mild COVID-19 infection or infection without symptoms are safe to return to sports after recovery from all symptoms. For youth with more serious SARS-CoV-2 infection or who develop MIS-C, it is reasonable to consider selected CV screenings, such as an echocardiogram, blood tests for heart enzyme levels and other heart function screening, before returning to sports.

The COVID-19 vaccines can prevent patients from getting COVID-19 and decreases the risk for MIS-C by 91% among children 12 to 18 years of age. There has been concern about the risk for myocarditis after receiving the mRNA COVID-19 vaccines. The data indicate the benefits of getting the vaccines outweigh the risk for potentially developing vaccine-associated myocarditis. For example, for every 1 million doses of the mRNA COVID-19 vaccines in males ages 12 to 29 years (the highest-risk group for vaccine-associated myocarditis), it is estimated that 11,000 COVID-19 cases, 560 hospitalizations and six deaths would be prevented, whereas 39 to 47 cases of myocarditis would be expected. The FDA has granted an emergency use authorization for the mRNA vaccine manufactured by Pfizer-BioNTech for children ages 5 years and older, and that vaccine has full approval for all individuals ages 16 years and older.

Viral infection is the most common cause of myocarditis in children. About one to two in every 100,000 children are diagnosed annually in the United States with myocarditis before the COVID-19 pandemic, according to data from the CDC. Children are also more likely than adults to develop myocarditis as the result of a viral infection such as COVID-19. The CDC is continuing to follow myocarditis in children and young adults closely, particularly a possible connection to the mRNA COVID-19 vaccines.

“Although much has been learned about how the virus impacts children’s and young adult’s hearts, how to best treat cardiovascular complications and prevent severe illness and continued clinical research trials are needed to better understand the long-term cardiovascular impacts,” Dr. Jone said. “It is also important to address health disparities that have become more apparent during the pandemic. We must work to ensure all children receive equal access to vaccination and high-quality care.”