Transcription:
COVID-19 and Myocarditis in Athletes: How Concerned Should Parents Be

Bill Klaproth: (Host) When discussing athletics in COVID-19 a heart condition called myocarditis has become a hot topic, but what is myocarditis and how worried should we be about it when it comes to both collegiate level and youth sports? This fall two major college football conferences decided to not play while other conferences continued with their plans all along. So what did some of these officials see that others did not? Today, we'll ask Dr. Jason Johnson. Associate chief of pediatric cardiology and director of the cardiac MRI at Le Bonheur Children's Hospital, these questions, and more.  This is the Peds Pod by LeBonheur Children's Hospital. I'm Bill Klaproth, Dr. Johnson thank you so much for your time. So first off, can you explain to us what is myocarditis?  

Dr. Jason Johnson: (Guest) Myocarditis just means inflammation of the heart muscle.

Host: Okay. So inflammation of the heart muscle, that doesn't sound good, right from the outset. So how does one get myocarditis and how does one get it without testing positive for COVID-19.

Dr. Johnson: Yeah. So don't want myocarditis, you don't want inflammation of your heart muscle. Myocarditis typically occurs from the body's immune system reaction to an infection, like a virus. So myocarditis can be caused by other disease processes that lead to inflammation, like even lupus. However, most cases of Myocarditis are actually related to an infection. And the leading causes of those would be a viral infection. Many other viruses can cause myocarditis like influenza or RSV and you can get myocarditis without even contracting COVID-19.

Host:  And what are the effects of myocarditis? What does that do to the heart?

Dr. Johnson: So, what that typically can do to the heart is it can lead to heart muscle damage, which we would see as a scar in the heart, or it could lead to heart muscle swelling, which we call edema. And if those processes are severe enough, it can cause decreased heart function. It can cause the heart muscle to dilate. Those would make you feel ill, so you would have chest pain or shortness of breath, or you'd be very fatigued specifically with activity.

Host: Got it. So then how often do you see myocarditis in your clinic?

Dr. Johnson: Thankfully myocarditis is rare. The incidence in the population is around one in 100,000 people. So it's pretty rare to contract myocarditis. In the Memphis area, we typically will diagnose this around 20 to 30 times a year. If it does occur, we do diagnose patients with it but thankfully it is rare.

Host: So then what is the average age of a patient with myocarditis?

Dr. Johnson:   Most of myocarditis will present in teenagers and even more specifically in males. Myocarditis can be diagnosed at any age. It can be diagnosed in a baby even much older patients, but it's very common into a younger age people, teenagers, or young adults

Host: And then how do you test for this?

Dr. Johnson: When a patient presents with symptoms concerning for myocarditis. So they've had a recent viral infection. They may have a cough or runny nose. They may have had, vomiting, and then they also more than likely will have chest pain. We will order some screening tests to evaluate that heart function. The first thing we would do is an electrocardiogram, which looks at the electrical activity of the heart. Then we would order an echocardiogram, which was look at the heart function itself. And then we would also order a blood test called a troponin that would look for heart muscle damage. And if that troponin is elevated, then there's evidence of heart muscle damage. We would order a more specific test called a cardiac MRI. The cardiac MRI can evaluate the heart muscle swelling called the edema or the heart muscle damage called scar.

Host: So then what is the treatment once it's found in a patient?

Dr. Johnson: Most cases of myocarditis are due to a viral infection. And so the treatment is actually centered around decreasing the inflammatory process. There are no real good active therapies to treat a viral infection per se. And so a common therapy is called IVIG or if specifically immunoglobulin and an immunoglobulin is basically the part of the blood that helps you find infection. And we pool that from several thousand people that donate blood. And then that has antibodies that help you fight infection. And so we can make sure that's safe and then we can give that to the patient that has myocarditis and it will help them, decrease the inflammatory process. If that doesn't work, then we can give steroids, and that will decrease the inflammatory process as well. And then if your heart muscle has decreased heart function, then there are medications that we can give to help the heart muscle function better.

Host: So when you clear the infection, you clear the myocarditis?  

Dr. Johnson: Well, yeah, the clearing of the infection will take away the ongoing inflammatory process typically. Now, in some rare instances, the body will be confused and it will think that its own tissue is the viral particles. And so it will attack its own self about four to six weeks after an infection. And we are seeing this with COVID-19, it's called multi inflammatory syndrome in children. And that will create an inflammatory process around four weeks after the initial infection. And so you can clear the infection, but then have an inflammatory process, many weeks after. We would want to treat the inflammatory process and not necessarily the infection.

Host: So then what does recovery look like?

Dr. Johnson: Thankfully, most patients will recover and have little lasting effects from myocarditis. They will require a period of rest, from exercise to allow their heart muscle to recover but they usually do not require lifelong medications. However, some patients will have significant heart failure.  Patients with heart failure will require the multiple medications as we previously discussed. In patients where the medications treat heart failure are not successful, they may even require more serious forms of treatment, like a ventricular assist device or a heart transplant. Thankfully serious, heart failure after a myocarditis is quite rare.

Host: So you said this is due to a viral infection. So then myocarditis has become a very popular topic over the past few months, is that because of COVID-19?

Dr. Johnson: Yes. Exactly, as you said, COVID-19 is a virus and like any virus, COVID-19 can cause myocarditis. So it was so many COVID-19 cases across the world and in the United States, there has been a lot of concern about, COVID-19 associated myocarditis. and then specifically the concern myocarditis in healthy athletes after COVID-19 has been discussed as a potential reason for limiting sports participation.

Host: So as mentioned in the open, some school districts have decided to not play fall sports while others have already begun playing. And we talked about college football as well. Do you think these are both reasonable perspectives, not playing and playing?

Dr. Johnson: This is a tough question to answer.  The decision to play sports in this pandemic should truly be left to the medical experts in epidemiology and infectious disease. The reason even the cancel sports should be related to active transmission and the community, and whether or not the sport can be effectively played with social distancing when wearing masks. Exactly it can be appropriately screened and tested in a community then participation is reasonable. Potential risk for myocarditis from any virus, including COVID-19 is low and should not be the reason to cancel sports. The initial concern of possible myocarditis likely contributed to the decision to cancel sports, on some level. However, experts in sports medicine and myocarditis now in agreement that canceling sports just because of myocarditis is really not warranted. And we're actually now witnessing school districts and large college conferences, like the big 10, changing their mind about sports participation in the fall when recently the big 10 announced that it will, start to have a football season at the end of October.

Host:  So as a precaution and should every athlete be tested for myocarditis before starting the season or after testing positive for cOVID-19 just to make sure?  

Dr. Johnson: Yeah, so that's a big question we're getting, constantly in the community, especially from pediatricians.  Any athletes should have a yearly history and physical, with their pediatrician or their primary care physician. That process is important to screen for other potential disease processes that would limit sports participation, including myocarditis. But specific cardiovascular testing for myocarditis with, blood tests and imaging studies would not be advised unless the history and physical were abnormal. Now specifically after a COVID-19 infection, we would not recommend cardiovascular testing if you are asymptomatic.  After 14 days, you should be clear for activity after you've discussed that with your primary care physician. Now if you've had moderate symptoms, with a prolonged fever, shortness of breath, and then you probably should get a screening electrocardiogram. And if that electrocardiogram which looks at the electrical activity of the heart is abnormal, then we would recommend, evaluation by a cardiologist, and probably recommend that blood test and maybe the echocardiogram. And if those tests were abnormal, then we would go onto the cardiac MRI. And then if you had a severe case of COVID-19 where you had to have, be admitted to the hospital, and required medications, a cardiologist would need to confirm that you had no lasting effects from that viral infection before returning to sports participation.

Host: So then what is your level of concern about the cardiovascular impact of COVID?

Dr. Johnson: That's an excellent question.  In a healthy population, so healthy, competitive athletes, either in high school or college level, the risk of myocardial problems after COVID-19 is quite low. The ongoing studies would just that patients who have multiple other health problems are the patients that are going to be at high risk for developing a heart problem after COVID-19.

Host: So just to clarify then, and you really laid this out for us that the potential risk is very low. So then in your expert opinion is the concern of heart damage and myocarditis enough to cancel youth sports?

Dr. Johnson: No. The concern for heart damage from myocarditis after COVID-19 is not a reason to cancel youth sports. The decision to cancel sports should be related to the viral transmission and the rates of the virus in the committee. But the potential for a low-risk problem of myocarditis and a healthy teenager or young adult should not be the reason to cancel sports.

Host:  So there are other valid reasons to cancel youth sports concerning COVID-19, but myocarditis shouldn't be the deciding factor it sounds like

Dr. Johnson: Exactly. Yes. myocarditis is being blamed for a lot of the reasons to not have sports participation but that's just not a clinically sound judgment. If we can safely, limit people's exposure to the virus, then the chance of them getting myocarditis is quite low. So myocarditis should not be the reason to cancel youth sports.

Host: Well, we're certainly learning a lot about COVID-19 and the effects on the human body. And we're going to continue to understand this virus better in the future. Like we're learning now about myocarditis. So Dr. Johnson, thank you so much for your time. This has really been informative thanks again.

Dr. Johnson: Thank you very much. It was my pleasure.

Host: That's Dr. Jason Johnson. And to learn more, visit Le Bonheur.org. And be sure to subscribe to the Peds Pod on Apple podcasts, Google Play, or wherever you listen to your podcasts. And you can always check out dot org slash podcast to view our full podcast library. And if you found this podcast helpful, please share it on your social channels. This is the Peds Pod by Le Bonheur Children's Hospital. Thanks for listening.