Myocarditis is the inflammation of the heart wall tissues that can affect the heart’s ability to pump blood, and sometimes cause an irregular or pathologically rapid heartbeat.
Dr. Sandeep is a general paediatric and fetal cardiologist and is currently the Medical Director of his practice Pediatrix Northwest Congenital HeartCare in Seattle and Tacoma in Washington state U.S.A, who has created a pathway to help paediatricians with the management of children with symptoms of myocarditis after COVID-19 vaccination.
Find out more about Pediatrix: www.pediatrix.com
Read the original research: pubmed.ncbi.nlm.nih.gov/36285797
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In this episode we will be looking at the work of Dr Nefthi Sandeep who has created a pathway to help paediatricians with the management of children with symptoms of myocarditis after COVID-19 vaccination.
In 2021, the Pfizer-BioNTech mRNA based COVID-19 vaccine was approved for its use in children. As the numbers of vaccinated children started to increase, some of them developed myocarditis, a rare but potentially serious complication characterized by inflammation of the heart wall tissues. Unfortunately, at most paediatric centres there remains no standard protocol for the management of this situation. Dr Nefthi Sandeep and his team at the Mary Bridge Children’s Hospital, Washington, USA, have reviewed the existing literature and formed a pathway to help paediatricians make decisions about how best to manage these children.
Myocarditis is the inflammation of the heart wall tissues that can affect the heart’s ability to pump blood, and sometimes cause an irregular or pathologically rapid heartbeat. In severe cases, the condition can also permanently damage the heart. The disease usually presents with an acute chest pain and shortness of breath. The presentation of the disease can vary with some patients having minor symptoms only, and others requiring admission to hospital as their heart function becomes compromised. Rarely, it can lead to severe heart failure, and even death. The most common cause of myocarditis in children is a viral illness, but often the cause remains unknown. Some vaccines have also been shown to cause myocarditis, including the Pfizer-BioNTech mRNA based COVID-19 vaccine.
After the Pfizer-BioNTech mRNA based COVID-19 vaccine was approved for use in children in 2021, large scale vaccination programs were initiated in many countries around the world. Among the increasing numbers of vaccinated children started to appear cases of post-vaccination chest pain. These children were often diagnosed with myocarditis, and soon the scientific community identified a link between the vaccine and the disease. Myocarditis is a rare complication of the Pfizer-BioNTech vaccine, and the increasing numbers of cases at the time put an unexpected extra strain on emergency and paediatric departments globally, most of which lacked a standard method of care for dealing with this specific vaccine related side effect in children.
Clinical decisions have so far been based on each department’s previous experience with the disease, and this means that most patients are admitted to hospital for observation, while some are followed up at treatment clinics. Treatments can vary from simple medication against inflammation, steroids, and in some cases more sophisticated immune-therapies, such as intravenous immunoglobulin – a solution of antibodies that helps the body fight the disease.
In addition to routine heart tests with ECGs and echocardiograms, some patients undergo MRI scans of the heart. The COVID-19 experience has given clinicians and researchers plenty of data and there are useful results from multicentre studies already available. With an aim to standardise the care of children that visit the hospital with myocarditis symptoms after their vaccination, Dr Nefthi Sandeep and his team have reviewed the recent literature and combined it with their own clinical experience during the pandemic, to design a reliable pathway to act as a guideline for the management of children with COVID_19 vaccine-related myocarditis. According to the team, this pathway can help reduce unnecessary variations in management and decrease the use of costly and less ubiquitous healthcare resources while still ensuring patient safety.
To enter the pathway, a child must have had the vaccine within the last 14 days and also present with all of the following : chest pain, shortness of breath, a COVID-19 negative PCR test and a normal temperature. These criteria were based on the findings of multicentre studies, including presentation of the symptoms up to 10 days after the vaccination. The next step is for these children to undergo a number of basic tests including among others a heart trace or ECG, a troponin I test, which indicates the presence of any heart damage, and if available on an emergency set up, an echocardiogram, which is an ultrasound scan of the heart.
Based on the child’s presentation and the results of the tests, the pathway next helps the paediatrician to decide if the child needs to be admitted to hospital. More specifically, the protocol suggests that the child could be sent home if they have a satisfactory ECG, troponin I levels and echocardiogram. It is understood that there might not be a children’s specialist always available to perform the scan, but the team believes that even a limited examination by an adult trained specialist should be enough. This step makes a big difference in the management of these children, especially since at the moment most of them are getting admitted for observation, treatment or further tests, something that could in many cases be avoided and save the hospital valuable resources.
After a child that meets the criteria has been admitted for treatment, the team suggests that the first line treatment should be medication against inflammation called non-steroidal anti-inflammatory drugs, or NSAIDs, with or without the addition of a pain killer called acetaminophen. They have also determined a number of specific criteria to help paediatricians decide whether the child would benefit from additional treatments such as steroids and immunoglobulin therapy.
These criteria include certain troponin I levels thresholds, lack of clinical improvement and abnormal findings on the ECG and echocardiogram. It is hard for the team, though, to come to definite conclusions regarding the treatments of choice, especially since during the pandemic most of the children would receive the additional treatments regardless, and there was overall a very low level of readmissions, heart complications, and deaths to provide solid evidence regarding their absolute necessity. These results make the benefits of the more advanced treatments such as immune therapy unclear.
Similarly, the additional data received from heart MRI scans, that were in some centres broadly used, were not always useful to the clinicians. In some cases, abnormal findings on the initial MRI tests only triggered follow up MRI scan that may be unnecessary. Additionally, not all centres have this facility available which means a protocol including a standard MRI scan would have to include patient transport and cause a lot of unnecessary disruption to the hospital’s function and overutilization of its resources. These are the reasons why Dr Sandeep suggests that the heart MRI scans should be reserved for the children whose symptoms worsen or do not improve on the additional treatments.
Overall, doctors and researchers around the world still have a limited understanding of myocarditis related to the COVID-19 vaccination in children. Dr Sandeep and his team believe that although there is still a lot to learn from the ongoing studies, their innovative treatment pathway can help reduce the number of unnecessary hospital admissions, shorten the length of stay at the hospital, and limit the unnecessary use of expensive treatments and tests.
The protocol can be applied at all paediatric centres including those without direct access to specialised paediatric cardiology facilities. Clinicians must remember that this pathway is a guiding tool and not a set of rules, and that it should be used in combination with their clinical judgement. As new knowledge becomes available to doctors it will be adjusted and continue to evolve so that it becomes an invaluable tool for both clinicians and researchers who continue studying these patients.
Dr. Sandeep is a general pediatric and fetal cardiologist and is currently the Medical Director of his practice, Pediatrix Northwest Congenital HeartCare in Seattle and Tacoma in Washington state USA.
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