Previously recorded May 10, 2020
Dr. Alain Bouchard and Dr. Mustafa Ahmed are joined by Dr. Mark Law, a pediatric cardiologist at Children’s of Alabama, and Dr. David Fieno of Shelby Baptist Medical Center to discuss the effect of COVID-19 on children’s cardiological health as well as its relationship to Kawasaki disease.
Transcript
Dr. Philip Johnson
This is the MyHeart.net podcast. The show is produced by Dr. Philip Johnson in conjunction with VitalEngine.com. Please welcome your host, Dr. Alain Bouchard in Birmingham, Alabama, at St. Vincent’s Medical Center.
Dr. Alain Bouchard
Welcome to our podcast, COVID-19 and the heart. Joining me today are Dr. Mustafa Ahmed, Chief of Cardiology Interventional and Structural Program at the University of Alabama in Birmingham, Dr. David Fieno, cardiologist at Shelby Baptist Medical Center, and Dr. Mark Law, pediatric cardiologist at Children’s Hospital in Birmingham, Alabama.
Welcome, gentlemen. And today, we’re going to discuss COVID-19 and the heart. And I’d like to say first that it’s a situation that is very, very fluid. What we talk about today, current analysis or discussion, will probably be totally modified in about a month or two. I mean, after all, it was just in February or March that we were describing case reports from Italy, as well as from China, single-center reports from China. And now we’re starting to have reports from multiple hospitals, particularly out of New York.
Also, some of the percentages that we’re going to mention are very likely skewed, because we haven’t had enough tests. Not enough people are being tested, as well as some people are completely asymptomatic. So it’s very difficult to draw a conclusion or at least an exact conclusion, and all the numbers that we’re going to talk about are mostly estimates.
The second point I want to make, which I think is very important with this COVID-19, is that any viral infection can affect the heart. And we have, for example, a viral illness, particularly with influenza, that can have a systemic inflammation as well as local at the level of the cells inside the arteries and can cause a ruptured plaque. As a matter of fact, we know, for example, during flu seasons, there’s more heart attacks and people dying from the heart than people dying from pneumonia. As well, viral infection can cause irregular heartbeat, or, you know, heart rhythm abnormality. We know from studies, for example, that with patients with heart failure and ICDs, there are more CD shocks during flu season.
In addition, we know that any viral infection can cause acute heart failure, whether it’s due to myocarditis, or whether it’s due to severe hypoxemia, and trigger a cytokine storm where the immune system goes flaring out of control, or whether it’s a stressed cardiomyopathy like we’ve seen sometimes with takotsubo in patients that have such stress in the ICU on the ventilator or on the respirator can have cardiomyopathy triggered by stress.
The other point that we want to bring today is that COVID-19 can affect kids. And this is the reason why we have a pediatric cardiologist here. Some people may have thought that maybe this is a mistake, I’m in the wrong podcast. But you know, as kids are returning to school in certain countries, we know that obviously there are some patients that are more predisposed to a viral infection. The ones with diabetes, hypertension or heart failure, but children also can be affected by this viral illness and viral infection. Particularly, we’ve seen some with COVID-19. Dr. Law, I’d like to have maybe your input and your impression as to how many patients are presenting at the Children’s Hospital with a viral infection and particularly with positive COVID-19.
Dr. Mark Law
So in our region, the number of patients in the hospital has been very few. The hospitals testing all the inpatients getting admitted to try to screen for asymptomatic carriers and even before elective procedures and surgeries and… Just to make sure that we’re identifying in the general population and trying to keep everybody safe. But the number of hospital admissions has been consistently in the one to two range with the PUIs, or the person under investigation, being in the less than 10 range, with that being a different category than all patients being screened. So in our community, we haven’t seen the COVID-19 in- infection and the problems related to the heart.
Now that said, there are increasing reports from places that have had higher numbers, such as Spain and Italy, and now in New York, and I think there is a case also from California, of COVID-19 presenting less respiratory but more of a shock syndrome, shock and potentially mild carditis or a multi-organ injury. And then there’s this newest entity which I’ve seen over the lay press, which I don’t see that it’s been readily published in the literature or peer review, but there’s a lot of discussion about Kawasaki disease and COVID-19. Kawasaki disease is an illness that’s diagnosed by multiple features – a rash; swollen lymph node; red, dry, cracked lips; red tongue; and conjunctivitis. And it can present with fever along with those symptoms for a number of days. Then ultimately the grouping of symptoms leads to the diagnosis and the treatment, which is immunoglobulin.
As a cardiologist, we see kids with Kawasaki disease because the end result, which ends up being coronary artery involvement, or coronary artery aneurysms, and that’s on the most severe end of Kawasaki disease. But you can also see Kawasaki disease with aneurysms and significant cardiac, myocardiac involvement, or myocardial involvement with dysfunction, and mitral regurgitation, valve leakiness. The reports that are coming out are now this association with kids with rash and fever and systemic inflammation and meeting the acute diagnosis for Kawasaki disease, but I’m unaware of how many of those kids are actually moving on to have a diagnosis of coronary artery aneurysms versus having Kawasaki disease with diffuse or – excuse me – with COVID-19 disease and diffuse inflammation and cardiac dysfunction and whether it’s more of a myocarditis picture in a multi-system injury picture.
Dr. Alain Bouchard
Do you see Kawasaki in kids pretty often on a regular basis, Mark?
Dr. Mark Law
We do see Kawasaki disease regularly in the hospital, and it’s very common for us to make that diagnosis. Now the number of kids that have Kawasaki disease with the true definitive diagnosis, which means you get coronary artery aneurysms, is a really small percentage. Making the firm diagnosis is often debatable because you can have incomplete Kawasaki disease with only some of the symptomatology versus what we would consider fulminant Kawasaki disease, which is cardiac involvement and coronary artery aneurysms.
The strange thing with Kawasaki disease is for years we’ve debated what causes it. Is it triggered by a viral infection? People have alluded to certain viruses or bacterial infections. And then there’s been environmental entities. There have been seasons of, like, the wind patterns in the Pacific Ocean have been indicted as changes for the epidemiology of Kawasaki disease because it seems to come in waves. But nobody can actually put their finger on what causes that. One of the things that I haven’t seen talked about but I find interesting is Kawasaki disease has a higher incidence in East Asia, and especially in Japan. But I haven’t seen any reports of COVID-19 and Kawasaki disease coming out of East Asia or the Japanese literature, to my knowledge.
Dr. Alain Bouchard
It’s interesting that some of the cases that they were describing, the kids were 10. I mean, usually, these are pretty young kids with Kawasaki, right? They’re usually less than five years old.
Dr. Mark Law
The majority of kids diagnosed with Kawasaki disease are less than five. And the kids that tend to have the most severe Kawasaki disease are less than one. And some of the reports that are coming out with the significant illness associated with COVID-19 seem to be older kids, older than five into the teenage years. So that seems to be a little bit different epidemiology for that pattern of COVID-19 associated with possible Kawasaki disease.
Dr. Alain Bouchard
There was some concern that with the stay-at-home orders and people being scared of going to the hospital that the Kawasaki-affected patients were at home undiscovered and untreated, therefore, and maybe raising the fear that we may have more severe case of coronary aneurism later on.
Dr. Mark Law
Yeah, we try to treat Kawasaki disease within the first week. Technically, you have to have a fever for five days. But if you get out to more than 10 days or more than 14 days, the data for IVIG and prevention of coronary artery aneurysms shows that the risk goes up. And so I think we’ve seen this in different medical specialties is people’s fear to seek medical attention of COVID-19. And so it’s easy to understand how a child might be well enough with fever or maybe even test negative for influenza or strep or maybe even get a COVID-19 test and then stay at home because the families are afraid to go out and seek other medical care and delay the diagnosis beyond 10 days or 14 days and then potentially develop coronary artery aneurysms from Kawasaki disease that’s been untreated.
Dr. Mustafa Ahmed
So, Mark, just to clarify, the reason this has become a point of conversation is because a lot of newspapers over the last two weeks have been talking about this mysterious inflammatory syndrome. And you’ve probably heard all this and talked about it a lot more than us. What’s the talk in the pediatric world about that syndrome? For people listening that don’t know what Kawasaki’s is, this is what’s being compared to as a potential similar syndrome, and people are wondering whether this triggers this in people. Or are people thinking this is a slightly different thing? And are you actually seeing this spike now, because of all the news reports of people suddenly wanting to come and get care and, in hospital, have heart tests?
Dr. Mark Law
We haven’t seen a spike in people presenting and wanting to get care. There’s a lot of chatter on different listservs about a single patient or two or three patients that test positive for COVID-19 who have been presenting in a shock in- an inflammation type of syndrome. So they come in in shock. Their echocardiograms may show depressed function. They have lots of in- inflammation for all the different tests that are, that are being performed. It’s not clear to me how much of that is actually overlapping with Kawasaki disease versus just a fulminant viral illness.
And then there’s a lot of chatter about it not being the fulminant viral illness, but a post-inflammatory type illness, where the immune system gets revved up after the infection and starts an immunologic response that just causes so much inflammation that they end up presenting in shock. That characteristic, I think, is different than what the initial reports for all the adults are. That’s standard adult reports, which is- which is really respiratory in nature, ARDS, as far as the COVID-19, classic SARS, which I think I’m here to learn a little bit more about what the adult presentation for COVID-19 in the myocardial stuff, and whether it’s myocardial infarction, whether you guys are seeing myocarditis or arrhythmia, or if it’s patients who are at-risk who are then getting stressed and then having cardiac complications secondary to their illness.
Dr. Alain Bouchard
Well, I think the- Yeah, good. Before the- I was kind of mentioning, you know, from the CDC was describing the COVID-19 as a pandemic, as primarily being a respiratory problem with 80% actually presenting with symptoms of cough and shortness of breath. But 80% of the patients, and this is just an estimate again, presenting with mild symptoms, while approximately 15% have moderate to severe disease and require hospitalization, and another 5% with very critical illness presenting with acute respiratory distress and shock and requiring ICU intubation and sometimes even ECMO. And I think what we’re looking at is probably a potential of 15-20% of patients that may have their heart affected by this illness. To keep that just in perspective, when we talk about this pandemic in the adult. That’s the CDC estimate. David, Dr. Fieno, you were gonna mention something?
Dr. David Fieno
Yeah, Mark, and I would be interested, Doctors Ahmed and Bouchard, about your opinion on this. You know, 20 miles away down in Alabaster, just about every one of these COVID-19 patients has a positive troponin, something, like, in excess of 80%. And, like the rest of the world, a lot of people, the ones that we pay attention to, and I’m talking about in-patients, particularly ICU patients, they’re pretty sick by the time we’re testing them. So we also have a very high sensitivity troponin, which is a conversation unto itself, right? But I think the points about a real substantial risk of myocarditis, and then a very substantial risk of a coronary event that’s related to the stress that’s caused with the illness, I think that’s definitely something we all have to keep in mind. It makes everything worse, is my feeling.
Dr. Mustafa Ahmed
So, Mark, while we kind of have you on the line, a few questions. What is the advice currently to kids or parents that come in contact with people that have had COVID? What is the treatment for that? Are they isolating or not? Is it being taken very seriously in kids’ communities? And I say that because many schools are thinking about potentially reopening. And is this something that concerns people, because when the whole COVID crisis first started, it was seen as this disease that kids didn’t really get affected by and people weren’t really worried about it. Is that changing over time? And what kind of advice are you giving people?
The other thing is, are kids seen as a large vector of disease, which means, you know, are they kind of carrying this thing? Because there’ve not really been many tests, right, in kids. There’ve been hundreds of thousands, millions of tests in adults, but no one’s really tested kids. What advice are people giving to them?
Dr. Mark Law
So I think that brings up a number of different issues. One is because of how the testing has been done with limited tests initially, and then more tests, but still not really the ability to do rapid mass screening. We’re not- we’re not to that place yet. So you’re holding back from the beginning on testing your least vulnerable population, which is still felt to be kids. And then if kids have contacts, the recommendation has been to quarantine.
And for the most part, I think that’s a population that has been able to quarantine because the schools have been closed and canceled, and so kids haven’t been in close contact with each other. It doesn’t make a lot of sense to me that kids wouldn’t get the virus if come into contact, and that we have to be under-recognizing the population of kids who actually have the virus. And my bias in listening to how other countries have potentially opened and how the public health people talk and how the Alabama public health people talk is, when you think about restoring mass gatherings, you have to think about identifying carriers and quarantining people who are exposed, and that’s going to have to involve mass testing.
And I think in order to get to that point of reopening schools, colleges, and- and high schools and middle schools, grade schools, that we have to identify which kid is going to walk into the school and have the virus, who they could have spread it to, who then contracts it, and then how they’re quarantined. I think that’s not necessarily talked a lot. It may be talked about in the school administration about doing that in the future, but I think they have a really high potential to be vectors, and that we’ve sort of quieted them down as we’ve closed schools.
Dr. Mustafa Ahmed
Do they have the same symptoms? Do kids have the same symptoms as adults or are they asymptomatic?
Dr. Mark Law
I think we’ll find that if we tested lots of kids that we would find that the same proportion of kids would test positive as the proportion of adults in the community.
Dr. David Fieno
We’ve seen at least two patients with adult congenital heart disease that had been surgically corrected. One was a transposition of the great vessels and one was corrected tetralogy, and both of them were ICU patients. They were young, 20s, late 20s. And I know you and I share a number of patients who are kids who become adults with these things. The CDC doesn’t really have any definite recommendations on COVID and kids with congenital heart disease, but boy, my feeling is they go into heart failure and respiratory failure at the drop of a dime. And I wonder if you have any feeling for that. I wonder if you can help any of us out there managing these patients in the ICU. Just any thoughts at all?
Dr. Mark Law
Yeah, I think we don’t know what the effects of congenital heart disease at different age levels and COVID-19 are going to be. I worry that there are our babies less than one year of age who aren’t corrected, if they get the illness, that that stress may be enough, but we’re seeing so little lung disease that it’s a little hard to know for sure. But I worry the at-risk population could be the adult congenital population who will be at risk to get respiratory symptoms, and then the combination of their respiratory disease and their cardiac disease will land them very sick. I don’t know that I have any particular advice on how to how to mitigate that, if it happens, other than the same supportive care that other adults with other medical problems would present. Their risk is likely to be when they’re 20s or 30s as opposed to what’s often reported in the lay press as people over the age of 50 or 60 being at a higher risk. I think our 20 and 30 adults with congenitals will be at that same level of risk.
Dr. David Fieno
My feeling exactly, Mark. The second question I had is that, the peds population, there’s a huge incidence of asthma, reactive airways disease, seasonal allergies, and we’re in the spring. I wonder if you have any feeling for- and I know you’re a cardiologist, but I wonder if you have any feeling for respiratory insufficiency that’s related to COVID and whether or not we’re seeing worsening asthma exacerbations that ultimately lead to hypoxic complications that we all get called for. I wonder if you had any feeling for that.
Dr. Mark Law
I don’t have too much to offer along those lines. I do wonder how our kids with significant asthmatic disease that often flare up when seasonal allergies flare up around this time, and whether the combination of kids with asthmatic disease, seasonal allergies, and then come across COVID-19, whether they will find themselves to have significant ventilation problems and need ICU support. I’d have to say at the moment, we haven’t seen that in the community, but I do wonder if that will be a presentation for the future.
Dr. Mustafa Ahmed
Oh, I have a question for you, Mark. So, in the adult hospitals, COVID led to this widespread shutdown, almost, at the beginning, while people were preparing for this onslaught, you know, of patients coming in. And a big concern for adults’ hospitals is people that need care, people that are having acute issues, they’re not coming to hospital. We’re still in the middle of the ramp-up process, as we call it. We don’t know if there’s gonna be a second wave of this thing.
Slowly, we’re seeing improvements, but we can talk about a number of conditions where adults are just presenting later with more severe disease with the damage already done and not getting the care they need. How’s this just affected at Children’s Hospital? Are there concerns that children that need care and are not presenting- and not just to a hospital, I mean, to primary care doctors and other doctors. Is there this thing that you’re seeing about people avoiding medical places and are there concerns and education that need to be done about that to stop bad things happening as collateral damage?
Dr. Mark Law
I think everybody has seen a drop in care on all sorts of levels, and it can be broken down in different aspects. So I think primary care essentially shut down for a period of time. So general wellcare, with the exception of immunizations, was pretty much done during April. And then it started to ramp back up in May. The same has been for our chronic cardiac care and outpatients for kids is our patients who come for their yearly visits have been postponed or delayed, with phone calls checking to make sure that they’re still functioning okay. And then it’s been kids who have had the need for elective procedures, whether they’re cardiac or non-cardiac. They have been put on hold for a period of time and are now just starting to come back. A lot of that’s been because of physician guidance and guidance from across the country. I don’t know, I’ve heard that ERs are slow, but I don’t know how many patients who have needed to get care, or that we can quantify the number of patients that needed to get care in the pediatric population who then had a delay. And that may be more challenging to tease out.
Dr. Alain Bouchard
Well, thank you very much, Mark. Unfortunately, I lost the internet on my computer, so I had to use the little iPad. But I want to thank Dr. Mark Law for your contribution to this podcast, and I think it really helps a lot to see a little bit more picture of a world that we don’t see that often, us in the adult cardiology. So thank you very much, Dr. Law, and appreciate, again, your great work at the Children’s Hospital.
Dr. Mark Law
Thank you. I look forward to joining you guys again.
Dr. Alain Bouchard
Thank you.
Transcribed by https://otter.ai
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