Highlights of the statement:
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Data suggests it is safe for youth with mild or asymptomatic COVID-19 to return to sports after recovering from symptoms. For those with more serious infections, it is reasonable to have heart exams, including an echocardiogram, blood tests to measure cardiac enzyme levels, and other tests to screen heart function before resuming sports or strenuous physical exercise.
Heart complications are rare but treatable for children and young adults after COVID-19 disease or SARS-CoV-2 infection, according to a new scientific statement from the American Heart Association that details what has been learned about how treat, control and even prevent cardiovascular complications of the SARS-CoV-2 virus in youth. The statement published today in the Association’s flagship magazine, Circulation.
The most recent data also indicate that it is safe to return to sports and strenuous physical activities after cardiac symptoms resolve, although additional screening may be considered for young people who experience more severe symptoms.
The new statement also calls for more research, including studies looking at the long-term cardiovascular effects of COVID-19 in children and young adults. The volunteer writing group’s extensive research on the most recent data found that children with congenital heart disease (heart disease or defects present at birth) have low rates of infection and complications from SARS-CoV-2, the virus that causes COVID-19 disease. A scientific statement from the American Heart Association is an expert analysis of current research and can inform future guidelines.
“Two years into the pandemic and with a large amount of research conducted on children with COVID-19, this statement summarizes what we know so far regarding COVID-19 in children,” said statement writing group chair Pei-Ni Jone, MD. , FAHA, director of 3D Echocardiography, Kawasaki Disease Clinic and Echocardiography Quality at Children’s Hospital Colorado in Aurora, Colorado. "We are focused on the effects of this virus for people with congenital or other heart diseases, as well as the most recent data on the possible association of COVID-19 vaccines with heart complications in children and young adults. While we know “Much, this public health emergency needs continued research to understand the short- and long-term impacts on children.”
Analysis of the latest research indicates that children generally have mild symptoms of SARS-CoV-2 infection.
In the US, as of February 24, 2022, children accounted for 17.6% of total COVID-19 cases and about 0.1% of deaths from the virus. Additionally, young adults, ages 18 to 29, have accounted for 21.3% of cases and 0.8% of deaths from COVID-19. Studies suggest that some factors may help explain why children may be less susceptible to severe COVID-19 infection: 1) cells in children’s bodies have fewer receptors for binding to the SARS-CoV-2 virus and 2 ) children may have a lower immune system. response due to a different cytokine response compared to adults and trained immunity from other vaccines and viral infections.
While children with congenital heart disease have had low rates of infection and mortality from SARS-CoV-2 infection, having an underlying genetic syndrome, such as trisomy 21 (also known as Down syndrome), appears to be associated with a higher risk of severe COVID -19.
The statement describes available treatments for children with COVID-19, although there are no specific antiviral therapies for COVID-19. These include remdesivir and dexamethasone for children in certain age groups. Remdesivir is the only antiviral medication currently approved by the US Food and Drug Administration (FDA) for the treatment of people over 12 years of age hospitalized with COVID-19 who have risk factors for severe disease and the need for supplemental oxygen, and is most effective when given as soon as possible after symptoms begin. Dexamethasone, which has been shown to reduce the risk of death in adults with COVID-19, is suggested for children with more severe illness who require respiratory support.
Heart-related complications in children with COVID-19 are rare. Case reports of cardiac complications include:
- Cardiogenic shock, in which a suddenly weakened heart cannot pump enough blood to meet the body’s needs.
- Myocarditis (inflammation of the heart muscle); pericarditis (inflammation of the pericardium,
a thin sac-like structure that surrounds the heart).
- Arrhythmias (irregular heartbeats and rhythms).
Sudden cardiac death and death after intensive medical and life-sustaining treatment have occurred in children with severe COVID-19 that affected the heart.
Since the beginning of the COVID-19 pandemic, a new multisystem inflammatory syndrome in children (MIS-C) has been identified worldwide, with up to half of cases involving inflammation of the heart muscle or heart arteries. During the first year of the pandemic, one in 3,164 children with SARS-CoV-2 infection developed MIS-C.
For children who develop MIS-C, intravenous immunoglobulin (IVIG) has been given alone or as dual therapy with infliximab or other immunomodulatory agents. Most children’s hearts recovered well within 1 to 4 weeks after MIS-C diagnosis. The risk of long-term complications and death from MIS-C is estimated to be 1.4 to 1.9%.
Most MIS-C cases occurred among children identified in medical records as black or Hispanic. Additional research on MIS-C is needed to learn why people from various racial or ethnic groups may be disproportionately affected and to understand the risk factors for this condition.
For children and young adults who have had COVID-19, returning to sports and strenuous physical activity has been an area of specific research and examination. The most recent data suggests that those who had a mild COVID-19 infection or an infection without symptoms can return to sports after recovering from all symptoms. For young people with more severe SARS-CoV-2 infection or who develop MIS-C, it is reasonable to consider selected cardiovascular tests, such as an echocardiogram, blood tests to measure cardiac enzyme levels, and other cardiac function tests, before to return to playing sports.
COVID-19 vaccines can prevent patients from getting COVID-19 and reduce the risk of MIS-C by 91% among children ages 12 to 18 . Some have expressed concern about the risk of heart inflammation after COVID-19 mRNA vaccines.
Data indicate that the benefits of receiving vaccines outweigh the risk of developing vaccine-associated myocarditis. For example, for every 1 million doses of mRNA COVID-19 vaccines in men ages 12 to 29 (the group at highest risk for vaccine-associated myocarditis), an estimated 11,000 COVID-19 cases, 560 hospitalizations and 6 deaths would be prevented, while 39 to 47 cases of myocarditis would be expected. The FDA granted Emergency Use Authorization for the mRNA vaccine manufactured by Pfizer-BioNTech for children ages 5 and older.
Viral infection is the most common cause of myocarditis in children.
About 1 to 2 in every 100,000 children were diagnosed annually in the U.S. with myocarditis before the COVID-19 pandemic, according to data from the U.S. Centers for Disease Control and Prevention. Children are also more likely than adults to develop myocarditis as a result of a viral infection such as COVID-19. CDC continues to closely monitor myocarditis in children and young adults, particularly a possible connection to COVID-19 mRNA vaccines.
More research is needed to better understand the mechanisms and optimal treatment approaches for SARS-CoV-2 infection, vaccine-associated myocarditis, long-term outcomes of COVID-19 and MIS-C, and the impact of these various heart conditions in children and young adults. Additionally, the development of new antiviral therapies should be tested in clinical trials focused on children.
“While much has been learned about how the virus affects the hearts of children and young adults, continued clinical research trials are needed to better understand the long-term cardiovascular impacts,” Jone said. “It is also important to address health disparities that have become more evident during the pandemic. We must work to ensure that all children receive equal access to vaccination and high-quality care.”
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Council on Lifelong Congenital Heart Disease and Young Heart Health; the Hypertension Council; and the Peripheral Vascular Disease Council. The American Heart Association’s scientific statements promote greater awareness of cardiovascular disease and stroke and help facilitate informed health care decisions. Scientific statements describe what is currently known about a topic and what areas need additional research. While scientific statements inform guideline development, they do not make treatment recommendations. The American Heart Association guidelines provide the Association’s official clinical practice recommendations.
