Selected Podcast
Cardiac Complications, Sports and Return to Play After COVID-19
Jeremy Archer, MD, MS, FAAP, discusses cardiac complications, sports, and return to play after COVID-19. He shares the cardiovascular complications of COVID-19 in the child and adolescent population. He app,lies the latest guidelines for return to play after COVID-19 and he offers the latest info on return to play after COVID-19 in a broader context of sports pre-participation evaluation.
Featuring:
Jeremy Archer, MD, MS, FAAP
Jeremy Archer, MD, MS, FAAP, is board-certified in pediatric cardiology and pediatrics. He joined the UF Health Congenital Heart Center and UF Department of Pediatrics as an assistant professor of pediatric cardiology in August 2020.From 2013 to 2020, Dr. Archer was a pediatric cardiologist at the Billings Clinic in Montana, where he built a pediatric and fetal cardiology practice to serve a wide geographic region in Montana and northern Wyoming. He was the medical director of Pediatric Specialty Medicine, the director of the pediatric echocardiography laboratory and, from 2018 to 2020, the co-founder and co-director of the Pediatric Chest Wall Deformity Clinic. Dr. Archer received his medical degree from UF in Gainesville. He completed his pediatric residency from the University of Vermont in Burlington, where he served as chief resident. Following residency, he returned to UF to complete a pediatric cardiology fellowship, also earning a master’s degree in health outcomes and policy. Dr. Archer’s research has focused on the impact of congenital heart disease in premature infants, and the economic impact of the early detection of congenital heart disease in newborns. Dr. Archer’s clinical interests include developing regional practice systems, sports and exercise testing, fetal cardiology, pediatric chest wall abnormalities and medical education. He is a member of the AAP Section on Cardiology and Cardiac Surgery.
Transcription:
Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we examine cardiac complications, sports, and return to play after COVID-19. Joining me is Dr. Jeremy Archer. He's a Clinical Assistant Professor in the Department of Pediatrics at the University of Florida. He practices at UF Health Shands Hospital and at the UF Health Congenital Heart Center in Gainesville, Florida. Dr. Archer, this is such a great topic. Thank you for joining us today. Can you clarify a little more between COVID infection and multi-system inflammatory syndrome or MISC and how it's affecting kids, while not very common. Tell us what you have been seeing.
Jeremy Archer, MD, MS, FAAP (Guest): Thanks Melanie. It's really great to be here. So, that's a great question. COVID-19 of course is the name of the virus and the infection that's caused this pandemic that's affected so many people over the last year and acute COVID-19 disease really refers to the direct effect of the virus on the body. And in both adults and in children, this can affect almost all the organs in the body, from the heart to the lungs, to the brain, to the kidneys and others.
Remember that in children, severe illness and death is much less common than in adults. Children are less severely affected. MISC or multi-system inflammatory syndrome in children is very similar, but it's actually a delayed response to the COVID-19 virus caused by the body's own immune system. And it's seen after infection, sometimes weeks or even longer after. It also affects all organs, but a little bit differently.
Host: Well, thank you for that. So, for other providers, how are patients presenting to primary care, maybe to their pediatricians. What are they seeing in clinic versus someone like you, a Pediatric Cardiologist? What are you seeing and how is this all different?
Dr. Archer: There's such a wide range of ways that patients can present with COVID-19 disease or MISC. The vast majority of children and even younger adolescents are either asymptomatic, meaning they discover they have COVID because a family member has it and they get it tested or somebody at school tests positive and they have to get tested, or they may be minimally symptomatic.
They may have mild cold symptoms, body aches, et cetera for a few days. So, these are the majority of patients that come in to see their pediatrician or primary care doctor. Some of them though, do have more prolonged disease or they may have symptoms that last for quite a while after the disease. They may be fatigued, they may be short of breath, et cetera.
So, those are the types of patients that are coming in to the primary care office. In the Cardiologist Office, we are tending to see the patients who were hospitalized with COVID, who may have actually had MISC. And we're seeing people with persistent symptoms, in particular cardiac symptoms, like chest pain, shortness of breath, et cetera.
Host: Well, then speak a little bit about once diagnosed, give us some EKG or echo cardiologist recommendations for imaging after a child tests positive Dr. Archer. What is the recommended evaluation like?
Dr. Archer: So that's a great question. And after a child tests positive, they really should always start with their primary care physician or other provider. Primary care doctor, pediatrician is the linchpin of post COVID care as they really are of any aspect of pediatric care. And so they are the ones who helps determine if the child needs to see a cardiologist.
That'll generally be if the duration of symptomatic illness was more than about four days, if there's cardiac symptoms or if they were hospitalized for COVID. If they do see a cardiologist, the cardiologists will generally start with an electrocardiogram, an echocardiogram and a troponin level to look for inflammation in the cells of the heart. And then they'll kind of determine if more testing like an MRI and exercise test needs to be done.
Host: Is there any difference with asymptomatic versus symptomatic or age related over under 12? Are there any differences in that evaluation you just spoke about?
Dr. Archer: There's quite a bit of difference. So, the kids who are asymptomatic truly asymptomatic, or if they had mild disease lasting less than four days, they really do not need to see a cardiologist. Those children based on all the published guidelines so far, can be cleared for return to activity by their primary care doctors.
And they ideally would follow a kind of graded return to play protocol, which we'll talk about later, but they don't need excessive testing. They don't need an echocardiogram and electrocardiogram. Whereas the children who are symptomatic, who had symptoms during their disease lasting four days or more, or if they have ongoing cardiac symptoms, those are the folks that need to see a cardiologist.
Those are the folks that are a little bit more risk. Now, the age of 12 is a rough guide to when most children have entered adolescence and the level of sports is more intense. So, we tend to screen those children a little more rigorously, both in terms of COVID and in terms of general sports screening. At this point, it's really important that nobody knows the exact risks of COVID in any age group. So, we're using data from other conditions that we screen for with sports and extrapolating them to COVID.
Host: Such an interesting topic we are discussing here today, Dr. Archer. And while we're discussing all of this, tell us about some of the available therapies and evaluation and one thing I find so interesting is this multidisciplinary approach for these children. So, when you're dealing with primary care providers and cardiologists and respiratory therapists and anyone else who was involved, tell us how that works, how you all work together and really who's in charge of the child's condition.
Dr. Archer: So that's a great question. It can be really complicated as you're pointing out to take care of children with issues with in many different organ systems. In the hospital, for the rare child who's hospitalized with COVID, the hospital pediatrician or pediatric intensive care doctors, are generally in charge, they're coordinating the care.
If the manifestation of the disease is primarily cardiac, the cardiology team will take a larger role. If it's primarily pulmonary, the pulmonary team will take a larger role, but they're really coordinating that. And that's mirrored on the outpatient side. This is a multiorgan disease. So, the pediatrician, the primary care physician is at the helm as they really are and should be with any complicated patient. So, they are making the referrals. They're gathering the referral information. They're ultimately the one that's going to closely follow the patient. And again, if there's a specialist that needs to be involved in a more significant way, they will be involved, but really the pediatrician is coordinating the care here.
Host: Well, thank you for that. So, now let's talk about return to play after COVID-19. Once cleared, how does an athlete get back to play? Apply for us the latest guidelines for return to play after COVID-19 and please place return to play in a broader context of sports pre-participation evaluations.
Dr. Archer: Yeah, absolutely. So, the bottom line is that we're trying to keep kids safe here. And there are a handful of conditions that can cause children and adolescents to collapse or die during sports. We obviously want to avoid that. And for any given child, that risk is very low, but of course, for children who are at risk and where this might be prevented that's the whole reason we have a sports screening infrastructure and program. That's why we do sports physicals. That's why they do screening EKGs universally in some countries in Europe. So, we have knowledge and lessons from this infrastructure from decades of experience with sports screening. Even though we don't know a lot about COVID yet, because it's just too new, we're able to apply that experience and that knowledge and come up with what's a pretty rational screening program for COVID. And so both the primary care physicians and the cardiologists have about seven or eight different published guidelines now to look at. On the one end of the spectrum, the asymptomatic child who tested positive can return to play in as few as 10 to 14 days after infection. On the other end of the spectrum, the child with myocarditis, either ongoing heart inflammation or fibrosis evidence of scarring in their heart, might need to wait six or more months to return to play and have repeated MRIs, exercise tests, et cetera. Once they get cleared to return to play, there's generally a graded progression that is recommended that children follow.
And this can be as little as a one week progression where they start out with maybe walking or light jogging for15 minutes, where they can carry on a conversation easily. If they feel fine, they might progress to 30 minutes of moderate exercise and so forth. For the children, who've had more severe disease, this is a more prolonged return to play and it might actually involve formal cardiopulmonary rehab services.
Host: Dr. Archer, as we wrap up. And due to the lack of evidence about cardiac injury from COVID, I mean, we're still learning so much, right? So, this isn't that common, relatively low number of pediatric cases. However, it's quite important as it is obviously to parents and to providers; so please wrap it up for us with your recommendations that are from your expert opinion in the cardiology department.
Dr. Archer: Sure. I think some of this is going to sound like a broken record to folks, but it's important and it bears repeating every time we talk about COVID. People should be wearing a mask. Everybody who's eligible, should be getting a vaccine. Most children are not eligible for a vaccine because they haven't been tested and approved in children.
So, adults should be getting vaccines to protect themselves and children. People should maintain a social distance from each other. People should stay home when they're sick. And if your child has had COVID make sure you talk to their doctor, for guidance about what to do to get them back to activity, to make sure they're safe. And the one thing I'd like for other physicians and providers to know about referral is that this is a complex disease. We're learning more all the time. So, if you're seeing a patient you're not comfortable with, or you're seeing a patient who's been hospitalized for COVID, call the pediatric cardiologist for advice or send the patient to us, and we'll be happy to work with you to take care of that patient in the best way we can.
Host: Such an interesting topic, Dr. Archer, thank you so much. I hope that you'll come back on as we're learning more and more, please come back on and update us once you get more information. To refer your patient, or to learn more about pediatric cardiology at UF Health Shands Hospital, please visit UFhealth.org/chc. Or you can call (352) 273-7770. Or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we examine cardiac complications, sports, and return to play after COVID-19. Joining me is Dr. Jeremy Archer. He's a Clinical Assistant Professor in the Department of Pediatrics at the University of Florida. He practices at UF Health Shands Hospital and at the UF Health Congenital Heart Center in Gainesville, Florida. Dr. Archer, this is such a great topic. Thank you for joining us today. Can you clarify a little more between COVID infection and multi-system inflammatory syndrome or MISC and how it's affecting kids, while not very common. Tell us what you have been seeing.
Jeremy Archer, MD, MS, FAAP (Guest): Thanks Melanie. It's really great to be here. So, that's a great question. COVID-19 of course is the name of the virus and the infection that's caused this pandemic that's affected so many people over the last year and acute COVID-19 disease really refers to the direct effect of the virus on the body. And in both adults and in children, this can affect almost all the organs in the body, from the heart to the lungs, to the brain, to the kidneys and others.
Remember that in children, severe illness and death is much less common than in adults. Children are less severely affected. MISC or multi-system inflammatory syndrome in children is very similar, but it's actually a delayed response to the COVID-19 virus caused by the body's own immune system. And it's seen after infection, sometimes weeks or even longer after. It also affects all organs, but a little bit differently.
Host: Well, thank you for that. So, for other providers, how are patients presenting to primary care, maybe to their pediatricians. What are they seeing in clinic versus someone like you, a Pediatric Cardiologist? What are you seeing and how is this all different?
Dr. Archer: There's such a wide range of ways that patients can present with COVID-19 disease or MISC. The vast majority of children and even younger adolescents are either asymptomatic, meaning they discover they have COVID because a family member has it and they get it tested or somebody at school tests positive and they have to get tested, or they may be minimally symptomatic.
They may have mild cold symptoms, body aches, et cetera for a few days. So, these are the majority of patients that come in to see their pediatrician or primary care doctor. Some of them though, do have more prolonged disease or they may have symptoms that last for quite a while after the disease. They may be fatigued, they may be short of breath, et cetera.
So, those are the types of patients that are coming in to the primary care office. In the Cardiologist Office, we are tending to see the patients who were hospitalized with COVID, who may have actually had MISC. And we're seeing people with persistent symptoms, in particular cardiac symptoms, like chest pain, shortness of breath, et cetera.
Host: Well, then speak a little bit about once diagnosed, give us some EKG or echo cardiologist recommendations for imaging after a child tests positive Dr. Archer. What is the recommended evaluation like?
Dr. Archer: So that's a great question. And after a child tests positive, they really should always start with their primary care physician or other provider. Primary care doctor, pediatrician is the linchpin of post COVID care as they really are of any aspect of pediatric care. And so they are the ones who helps determine if the child needs to see a cardiologist.
That'll generally be if the duration of symptomatic illness was more than about four days, if there's cardiac symptoms or if they were hospitalized for COVID. If they do see a cardiologist, the cardiologists will generally start with an electrocardiogram, an echocardiogram and a troponin level to look for inflammation in the cells of the heart. And then they'll kind of determine if more testing like an MRI and exercise test needs to be done.
Host: Is there any difference with asymptomatic versus symptomatic or age related over under 12? Are there any differences in that evaluation you just spoke about?
Dr. Archer: There's quite a bit of difference. So, the kids who are asymptomatic truly asymptomatic, or if they had mild disease lasting less than four days, they really do not need to see a cardiologist. Those children based on all the published guidelines so far, can be cleared for return to activity by their primary care doctors.
And they ideally would follow a kind of graded return to play protocol, which we'll talk about later, but they don't need excessive testing. They don't need an echocardiogram and electrocardiogram. Whereas the children who are symptomatic, who had symptoms during their disease lasting four days or more, or if they have ongoing cardiac symptoms, those are the folks that need to see a cardiologist.
Those are the folks that are a little bit more risk. Now, the age of 12 is a rough guide to when most children have entered adolescence and the level of sports is more intense. So, we tend to screen those children a little more rigorously, both in terms of COVID and in terms of general sports screening. At this point, it's really important that nobody knows the exact risks of COVID in any age group. So, we're using data from other conditions that we screen for with sports and extrapolating them to COVID.
Host: Such an interesting topic we are discussing here today, Dr. Archer. And while we're discussing all of this, tell us about some of the available therapies and evaluation and one thing I find so interesting is this multidisciplinary approach for these children. So, when you're dealing with primary care providers and cardiologists and respiratory therapists and anyone else who was involved, tell us how that works, how you all work together and really who's in charge of the child's condition.
Dr. Archer: So that's a great question. It can be really complicated as you're pointing out to take care of children with issues with in many different organ systems. In the hospital, for the rare child who's hospitalized with COVID, the hospital pediatrician or pediatric intensive care doctors, are generally in charge, they're coordinating the care.
If the manifestation of the disease is primarily cardiac, the cardiology team will take a larger role. If it's primarily pulmonary, the pulmonary team will take a larger role, but they're really coordinating that. And that's mirrored on the outpatient side. This is a multiorgan disease. So, the pediatrician, the primary care physician is at the helm as they really are and should be with any complicated patient. So, they are making the referrals. They're gathering the referral information. They're ultimately the one that's going to closely follow the patient. And again, if there's a specialist that needs to be involved in a more significant way, they will be involved, but really the pediatrician is coordinating the care here.
Host: Well, thank you for that. So, now let's talk about return to play after COVID-19. Once cleared, how does an athlete get back to play? Apply for us the latest guidelines for return to play after COVID-19 and please place return to play in a broader context of sports pre-participation evaluations.
Dr. Archer: Yeah, absolutely. So, the bottom line is that we're trying to keep kids safe here. And there are a handful of conditions that can cause children and adolescents to collapse or die during sports. We obviously want to avoid that. And for any given child, that risk is very low, but of course, for children who are at risk and where this might be prevented that's the whole reason we have a sports screening infrastructure and program. That's why we do sports physicals. That's why they do screening EKGs universally in some countries in Europe. So, we have knowledge and lessons from this infrastructure from decades of experience with sports screening. Even though we don't know a lot about COVID yet, because it's just too new, we're able to apply that experience and that knowledge and come up with what's a pretty rational screening program for COVID. And so both the primary care physicians and the cardiologists have about seven or eight different published guidelines now to look at. On the one end of the spectrum, the asymptomatic child who tested positive can return to play in as few as 10 to 14 days after infection. On the other end of the spectrum, the child with myocarditis, either ongoing heart inflammation or fibrosis evidence of scarring in their heart, might need to wait six or more months to return to play and have repeated MRIs, exercise tests, et cetera. Once they get cleared to return to play, there's generally a graded progression that is recommended that children follow.
And this can be as little as a one week progression where they start out with maybe walking or light jogging for15 minutes, where they can carry on a conversation easily. If they feel fine, they might progress to 30 minutes of moderate exercise and so forth. For the children, who've had more severe disease, this is a more prolonged return to play and it might actually involve formal cardiopulmonary rehab services.
Host: Dr. Archer, as we wrap up. And due to the lack of evidence about cardiac injury from COVID, I mean, we're still learning so much, right? So, this isn't that common, relatively low number of pediatric cases. However, it's quite important as it is obviously to parents and to providers; so please wrap it up for us with your recommendations that are from your expert opinion in the cardiology department.
Dr. Archer: Sure. I think some of this is going to sound like a broken record to folks, but it's important and it bears repeating every time we talk about COVID. People should be wearing a mask. Everybody who's eligible, should be getting a vaccine. Most children are not eligible for a vaccine because they haven't been tested and approved in children.
So, adults should be getting vaccines to protect themselves and children. People should maintain a social distance from each other. People should stay home when they're sick. And if your child has had COVID make sure you talk to their doctor, for guidance about what to do to get them back to activity, to make sure they're safe. And the one thing I'd like for other physicians and providers to know about referral is that this is a complex disease. We're learning more all the time. So, if you're seeing a patient you're not comfortable with, or you're seeing a patient who's been hospitalized for COVID, call the pediatric cardiologist for advice or send the patient to us, and we'll be happy to work with you to take care of that patient in the best way we can.
Host: Such an interesting topic, Dr. Archer, thank you so much. I hope that you'll come back on as we're learning more and more, please come back on and update us once you get more information. To refer your patient, or to learn more about pediatric cardiology at UF Health Shands Hospital, please visit UFhealth.org/chc. Or you can call (352) 273-7770. Or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.