Top Things to Know: SARS-CoV-2 Infection and Associated Cardiovascular Manifestations and Complications in Children and Young Adults
Published: April 11, 2022
Prepared by Paul St. Laurent, DNP, RN, Senior Science and Medicine Advisor, Lead
- Proposed mechanisms of cardiovascular (CV) involvement in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection include: 1) direct viral invasion of the cardiomyocytes where angiotensin-converting enzyme 2 (ACE2) receptors are highly expressed resulting in direct cellular damage, 2) cardiomyocyte injury due to overwhelming immune inflammatory response and cytokine storm, and 3) severe hypoxia resulting in ischemic myocardial injury.
- Acute CV manifestations of COVID-19 infection in children are uncommon and include cardiogenic shock, myocarditis, pericarditis and atrial and ventricular arrhythmias. Sudden cardiac death and death following intensive medical and supportive therapies has occurred in children with severe myocardial involvement.
- Remdesivir, currently the only antiviral drug approved by the FDA for treatment of hospitalized children > 12 years with risk factors for severe disease and an emergent need or require supplemental oxygen, is most effective when given early in the clinical course.
- Dexamethasone, which has been shown to reduce mortality in adults, is recommended in children who require high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).
- Multisystem inflammatory syndrome in children (MIS-C), a rare but severe post-inflammatory complication of COVID-19, can cause acute myocardial dysfunction, arrhythmias or conduction abnormalities, and coronary artery dilation.
- While robust clinical trial data are lacking, the first line treatment for MIS-C is typically intravenous immunoglobulin (IVIG) which is associated with a high rate of symptom improvement and recovery of cardiac function. Ongoing trials are evaluating the addition of infliximab, steroids, or anakinra after initial treatment with IVIG.
- Available data suggest it is safe to allow asymptomatic youth and those with mild infection to return to sports after recovery from COVID-19 infection and that it’s reasonable to consider screening youth with greater than mild infections or MIS-C with CV testing, including cardiac enzyme levels, ECG and echocardiogram, before return to sports.
- Children with congenital heart disease (CHD) appear to have low infection and mortality rates from acute SARS-CoV-2 infection however, the presence of an underlying genetic syndrome, such as trisomy 21, appears to convey an increased risk of severe infection.
- The benefit of the COVID-19 vaccine outweighs the risks of rare myocarditis/pericarditis temporally associated with vaccination. COVID-19 vaccination is still recommended to curb this pandemic, and there are active efforts to investigate potential long-term effects of myocarditis associated with COVID-19 vaccination.
- Although much has been learned on the pathology of this disease and treatment of children with COVID-19 and MIS-C, continued clinical research trials are needed to better understand the long-term CV manifestations in children.
Citation
Jone P-N, John A, Oster ME, Allen K, Tremoulet AH, Saarel EV, Lambert LM, Miyamoto SD, de Ferranti SD; on behalf of the American Heart Association Leadership Committee and Congenital Cardiac Defects Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Hypertension, and Council on Peripheral Vascular Disease. SARS-CoV-2 infection and associated cardiovascular manifestations and complications in children and young adults: a scientific statement from the American Heart Association [published online ahead of print April 11, 2022]. Circulation. doi: 10.1161/CIR.0000000000001064