Covid-19, or “coronavirus disease 2019,” is an illness caused by the SARS-CoV-2 virus. This virus was first identified in 2019, and by the end of 2021 had caused nearly 6 million deaths worldwide. In December 2020, the first Covid-19 vaccine was approved by the FDA for emergency use. Covid-19 primarily affects the lungs, but it can also affect many other organs, including the heart and blood vessels.

Information about Covid-19 continues to evolve based upon new research data and emergence of new strains, but medical science has learned a great deal about this virus in a short period of time.

Below are some answers to questions we are commonly asked by our patients.

How does Covid-19 infection affect the heart in children?

Covid-19 is less likely to significantly affect the heart in children compared to adults. When it does, it can cause myocarditis, pericarditis, and/or MIS-C. The risk of myocarditis in children with Covid 19 is very low (about 0.1-0.5%), but it is still much higher than the risk in the general population. The risk of MIS-C after Covid 19 infection is even lower, about 0.03%.

What is MIS-C?
MIS-C, or multisystem inflammatory syndrome in children, is the most severe complication of pediatric Covid-19 infection. MIS-C is an inflammatory syndrome that affects multiple organs, including the heart. It happens after a child has already recovered from their Covid-19 illness, usually within the first four weeks after infection (even if the infection was asymptomatic). Symptoms of MIS-C can include fever, diarrhea, vomiting, rash, shortness of breath, and red eyes. Children with MIS-C need to be hospitalized, and are often critically ill. Effects on the heart can include inflammation of the heart muscle (myocarditis) and the coronary arteries. Although some children have died from MIS-C, most children do recover.
I have a question about the vaccine and congenital Heart disease

My child has congenital heart disease, and I am worried about the risk of myocarditis after the Covid vaccine. Is it OK for him/her to get the vaccine?
Yes. The risk of myocarditis after a Covid vaccine is extremely low, at about 0.0005% (JAMA. 2022;327(4):331-340). Myocarditis can occur after an mRNA vaccine (Pfizer and Moderna), usually within a week of receiving the vaccine. Those at highest risk are adolescent and young adult males who have received two vaccine doses. Congenital heart disease does not make myocarditis more likely. Vaccine-associated myocarditis is typically brief and mild, whereas myocarditis from a virus (like Covid-19) tends to cause more serious illness. Because of that, the benefits of the vaccine are still felt to outweigh the risks.

My child has congenital heart disease. Does (s)he qualify for a medical exemption to the Covid-19 vaccine requirement?

Congenital heart disease is not a contraindication to the Covid-19 vaccine. In fact, patients with some types of congenital heart disease have been prioritized to receive the vaccine because they are at higher risk for severe illness should they become infected. Exemption from the vaccine can be considered in children who have had documented myocarditis or pericarditis following a Covid 19 vaccine dose, or those with a history of MIS-C. More information on contraindications and precautions to Covid-19 vaccination can be found here.

What is long Covid?

Long Covid is defined as symptoms related to Covid-19 infection that last longer than 4 weeks, and cannot be explained by a different diagnosis. Long Covid can occur both in children with mild/asymptomatic illness, and in children with severe illness. Symptoms of long Covid are highly variable, and can consist of combinations of fatigue, headache, dizziness, brain fog, shortness of breath, chest pain, continued fever, joint pains, digestive symptoms, and many other complaints. The cause of long Covid is still being investigated. If symptoms continue beyond 12 weeks, and are affecting the child’s quality of life, referral to a multidisciplinary long Covid clinic can be considered. Treatment is individualized, depending on each child’s symptoms.

What is myocarditis/pericarditis?
Myocarditis is inflammation of the heart muscle. Pericarditis is inflammation of the sac that surrounds the heart. Myocarditis and pericarditis can occur together or separately. Myocarditis can cause a decrease in heart function (how well the heart squeezes) and can cause heart rhythm abnormalities, which can be dangerous. Symptoms of myocarditis include chest pain, palpitations (a feeling of heart fluttering or racing), shortness of breath, excessive fatigue, or fainting. Myocarditis can be mild or severe; it can last a few days and cause minimal symptoms before resolving on its own, or it can cause a child to be hospitalized and have permanent damage to the heart. Myocarditis and pericarditis can be diagnosed using a combination of blood tests, EKG, and echocardiogram.
My child has congenital heart disease. Is s(he) at higher risk of severe illness from Covid-19?

This question is difficult to answer, because every case is different. The large majority of children with congenital heart disease are not at higher risk of severe illness from Covid 19. Patients with congenital heart disease are also not at higher risk for myocarditis or MIS-C. However, certain diagnoses may cause a patient to become more severely ill with Covid-19. Examples include pulmonary hypertension, cyanosis (chronically low oxygen saturations), Fontan circulation, some types of cardiomyopathy, or associated noncardiac conditions such as immunosuppression, lung disease, or some genetic syndromes or disabilities.

Why does my child need to see a cardiologist before returning to sports after Covid-19 infection?

Covid-19 is a risk factor for myocarditis, and physical activity is a known trigger for potentially dangerous heart rhythm abnormalities in people with myocarditis. Even if the myocarditis occurred weeks or months ago, there can be scarring in the heart that causes arrythmias. Because of this risk, the American Academy of Pediatrics recommends a medical evaluation before a return to exercise in children who had a Covid-19 infection, including those with mild or asymptomatic infection. Those who had moderate to severe illness (defined as at least 4 days of fever >100.4°F, or at least 1 week of muscle aches, chills, or lethargy) should have an EKG as part of their evaluation. Youth with heart-related symptoms or an abnormal EKG may need further cardiac testing before being cleared for sports. Children with MIS-C should be restricted from sports for 3-6 months.

In Oregon, the Oregon School Activities Association (OSAA) also provides guidance regarding sports participation after Covid-19 infection. OSAA guidelines may or may not differ slightly from AAP guidelines. Current OSAA guidelines can be found on the OSAA website.

After Covid-19 infection, return to sports should be gradual, and medical attention should be sought if, after return to physical activity, the child develops any new symptoms such as chest pain, palpitations, fainting or near fainting, or unexpected shortness of breath.

What are common cardiac problems with long Covid?
Children with long Covid can have symptoms related to myocarditis or arrhythmias, but the most common heart-related symptoms of fatigue, dizziness, and fainting are due to dysautonomia (link to patient education on dysautonomia), which is a problem with the nervous system, and not the heart. Because dysautonomia affects heart rate and blood pressure, cardiologists are often involved in the care of these patients.