AHA: Scientific Statement on SARS-CoV-2 and Cardiovascular Manifestations Among Children

The American Heart Association (AHA) released a Scientific Statement, published in Circulation, about SARS-CoV-2-related cardiovascular manifestations and complications among children and young adults.

COVID-19 presents acutely as cough, fever, shortness of breath, and hypoxia. Among adults, associated cardiovascular complications include myocardial injury, arrhythmias, acute coronary syndrome, and venous thromboembolism. Patients with preexisting cardiovascular diseases have had elevated morbidity and mortality.

For children and adolescents, most COVID-19 infections are mild or asymptomatic. In rare, severe cases, children and adolescents can present with multisystem inflammatory syndrome in children (MIS-C), which is associated with acute myocardial dysfunction, arrhythmia, conduction abnormalities, and coronary artery deflation.

The goal of this scientific statement is to review the current evidence about cardiovascular-related health consequences of COVID-19 among children and adolescents.

As of February 2022, children have accounted for 17.6% of total COVID-19 cases and 0.1% of total deaths in the United States. For young adults (aged 18-29 years), the proportion of total cases and deaths is 21.3% and 0.8%, respectively.

A systematic review of the literature found that 1.9% of the pediatric patient population (N=5686) required intensive care and mechanical ventilation due to COVID-19. Among severe cases, 75% had comorbidities, including heart disease or cardiomyopathy (21%), obesity (15%), asthma (10%), neurological disorders (10%), and hypertension (2%). Mortality occurred among 16% of the children with severe illness, or 0.3% overall.

To treat COVID-19 among children and adolescents, most patients require only supportive intervention. Patients who have dyspnea or comorbid chronic health conditions should be monitored and treated in a hospital setting. In addition to respiratory management, patients with severe disease may be candidates for antiviral and immunomodulatory therapy.

For special populations, such as those with congenital heart disease, pulmonary hypertension, heart failure, or for heart transplant recipients, there remains an overall paucity of data to establish guidance for predicting patient risk. Most available data for these groups have been sourced from adult populations. Careful follow-up of these children is advised.

In general, long-term outcomes remain unclear. However, available data suggests that youth who had asymptomatic or mild infections can return to normal activities, including sports, after symptoms clear.

A systemic review of MIS-C (n>900) found that children presented with fever (99%), gastrointestinal symptoms (87%), abdominal pain (70%), rash (59%), nonpurulent conjunctivitis (57%), and oral mucosal changes (42%). The median age of these patients was 8 to 9 years, 57% to 59% were boys, 35% to 37% were Hispanic, and 25% to 31% were Black. As many as 50% of this patient population had myocardial involvement, such as decreased left ventricular function, coronary artery dilation or aneurysms, myocarditis, and pericardial effusion. These patients tend to have favorable outcomes, with resolution of inflammation and cardiovascular abnormalities within 1 to 4 weeks, however, death occurred among 1.4% to 1.9%.

To treat MIS-C, patients should receive supportive therapies. For patients in need of supportive treatment of heart failure and vasoplegic shock, they should be managed in the intensive care unit. Current reports indicate that 70%-80% of patients with MIS-C receive intravenous immunoglobulin therapy.

Beyond direct outcomes from COVID-19 or MIS-C, the pandemic period has been associated with disruption to routine clinical care. A survey of parents of children with congenital heart disease or adults with congenital heart disease found that 38% have experienced a delay in surgery and 46% a delay in clinical visits. These delays in care may have implications for long-term cardiovascular outcomes.

Vaccination for COVID-19 could also be a factor to consider for cardiovascular health. A series of 63 patients (aged mean 15.6 years) found evidence of temporary myocarditis after receiving an mRNA vaccination. Most patients (86%) had resolution of symptoms with time. The Statement authors thought that the benefits of the COVID-19 vaccine outweigh the risks for this rare adverse event. Among boys or men, who are at greatest risk for this complication, 39 to 47 cases of myocarditis would be expected per one million vaccination doses, which would prevent 11,000 COVID-19 cases, 560 hospitalizations, and 6 deaths.

For the future, the scientific community will continue to gain better understanding of the risks and long-term outcomes of COVID-19 and MIS-C among children and adolescents.

The statement authors concluded, “SARS-CoV-2 infection continues to infect patients worldwide, with variants circulating in different parts of the world. We have much to learn about the pathology of this disease but have gained some ground on the treatment of COVID-19 and management of children with MIS-C. The long-term cardiovascular manifestations of COVID-19 in children require continued clinical research trials.”

Reference

Jone P-N, John A, Oster ME, et al. SARS-CoV-2 infection and associated cardiovascular manifestations and complications in children and young adults: A scientific statement from the American Heart Association. Circulation. Published online April 11, 2022. doi:10.1161/CIR.0000000000001064