Returning to Sports after COVID – PediaCast 472
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- Drs Tom Pommering and Simon Lee visit the studio as we consider student athletes with COVID-19. What is the real risk of myocarditis? Why is this heart condition dangerous? How do we screen for it? And when can student athletes return to play? We hope you can join us for answers!
- Returning to Sports After COVID-19
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 472 for September 11th, 2020. We're calling this one "Returning to Sports After COVID". I want to welcome all of you to the program.
So last week, we covered returning to school in the context of an ongoing COVID-19 pandemic. The world is certainly a different place compared to last Fall. And whether you've returned to in-person instruction in the classroom, distance learning, home schooling or a hybrid model of these choices, one thing is certain, many rules and routines have changed. And we talked about many of these changes last week, including which model of education to choose when given the choice.
Of course, it's not a one-size fits-all answer, so we talked about how you consider your family and making choices right for you.
We also talked about face coverings, physical distancing, handwashing, cohorts, and the COVID testing, quarantine, isolation. We've talked about outbreaks of COVID at school and what to expect if and when COVID shows up in your child's classroom. And we also talked about extracurricular activities like sports, band, choir, and drama.
So, if you have a child or several children attending school this fall, please consider listen to Episode 471 which we call "Back to School with COVID".
Now, there is one topic that we did not include in that episode, a topic so big and so important, we saved it as a standalone conversation this week. And that topic is returning to sports participation following COVID-19 infection or after testing positive for the SARS-CoV-2 virus which causes COVID-19. Even if your illness was mild or you seem to have no symptoms at all, it's fairly straightforward when you can return to school following COVID-19 illness. At least as of today, September 11th, 2020, things could possibly change as we learn more.
But, in general, as of right now, returning to school after COVID-19, you need ten days of isolation improving symptoms and no fever for 24 hours without the use of fever reducing medicine. Okay, that's when you can go back to school.
But what about sports? Can you just jump in where you left off like you might do after a cold or even about with the flu? Turns out the answer is no, and the reason is because COVID-19 brings a risk of heart inflammation known as myocarditis, even when the symptoms of COVID-19 infection are otherwise seemingly mild. And myocarditis brings the risk of abnormal heartbeats known as arrhythmias, which can result in sudden death of the student athlete.
Now, that may leave lots of questions in your mind, among them is this a rare or a common occurrence and what is the real risk? How can we best screen for the presence of myocarditis? And what do we do when we find it? How do we get our students back to play in sports safely following an infection with COVID-19?
To help me answer these questions and more, we have two terrific guests joining us this week. Dr. Tom Pommering is medical director of Sports Medicine at Nationwide Children's Hospital, and Dr. Simon Lee is a pediatric cardiologist with the Heart Center also at Nationwide Children's. They will be here shortly.
First though, another quick reminder about flu shots. It is that time of year. Get them, please, for your entire family.
September and October are prime months for protecting your family from the flu. Our family, we've all had our flu shot. The flu typically kills tens of thousands of Americans each year and getting your annual flu vaccine drastically reduces your chance of becoming very ill or dying from the flu.
You might still get the flu, but you can expect a milder illness and less chance of dying with that flu shot on board. So please think about where and when you're going to get your family protected against influenza during this COVID-19 pandemic. It is an important thing to do.
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So, let's take a quick break. We'll get Dr. Pommering and Dr. Lee connected to the studio. And then we will be back to talk about returning to sports after COVID. That's coming up right after this.
Dr. Tom Pommering is Division Chief of the Sports Medicine Program at Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine. Dr. Simon Lee is a pediatric cardiologist at Nationwide Children's and an assistant professor of Pediatrics at Ohio State.
They're here to talk about student athletes and returning to sports participation, following an infection with the SARS-CoV-2 virus which causes COVID-19.
So let's give a warm PediaCast welcome to Dr. Tom Pommering and Dr. Simon Lee. Thanks so much to both of you for being here today.
Dr. Tom Pommering: Really glad to be here.
Dr. Simon Lee: Same here.
Dr. Mike Patrick: Appreciate both of you taking time out of your busy schedules. So, Dr. Pommering, I wanted to start with just quick reminder for the audience. What is the pre-participation physical evaluation, kind of what we call the sports physical, what is it and why is that important?
Dr. Tom Pommering: So, before COVID, PPE to all of us meant pre-participation exam and that's what we're going to talk about now.
This is basically a state requirement. All of the 50 states have requirement that comes down from their athletic associations that oversees scholastic sports and they require an annual or biannual exam. And it was originally intended to tease out any injuries that might be dangerous to play on, any medical conditions that might be affected by athletics, and also the service sort of medical legal protection for them.
And it's debatable whether it accomplishes any of this, but it's an administrative requirement that the states require for the schools to do in Ohio every year.
Dr. Mike Patrick: And the thing is that when you see kids, especially if this is done in the medical home where you have a relationship with your medical provider, that it does provides some opportunity for anticipatory guidance. So doctors talking with families about things that are important that you may not be able to cover during the normal well-checkup. Because there's just so many things that we can talk about, but in this particular instance, we can talk about conditioning and training, and injury prevention, and diet as it relates to sports and sleep and mental health with sports and all those things.
And we did an entire episode on the sports physicals back in PediaCast Episode 424. And for those who'd like to hear more about those, I'll put a link in the show notes so you can find that particular episode easily. But would you agree, Tom, that really the medical home is kind of the preferred place for this exam to happen?
Dr. Tom Pommering: Oh, without a doubt. I mean, if you think about what really threatens the health and safety of our adolescents, it's not the sports injury per se. It's really things that relate to what's going on in their lives like high-risk behaviors, suicide, depression, risk-taking behaviors, things like that. And those are conversations that are absolutely best had between you and your primary care physician.
And those are in the PPE, part of the PPE exam but it's a better conversation to have with someone you know and trust.
Dr. Mike Patrick: The alternative is school-sponsored events that can be ran by a doctor that your child and your family does not necessarily know. Or it may be nurse practitioner, physician assistant, some places that maybe an athletic trainer. And then, the grocery store clinics often, it will say, "Sports physical, come on in." And I mean, if you can't get in to see your regular doctor, those things can be acceptable but not necessarily best practice, right?
Dr. Tom Pommering: Yeah, and like you said before, this is an opportunity to see adolescents who are normally pretty healthy. You're not coming in for immunizations like they were when they're babies, but their issues are really different than what we do in a sports exam. But unfortunately, the schools and a lot of parents look at this as sort of necessary administrative burden that they have to do to play sports.
And this really should be opportunities for them to touch base with their primary care docs again and talk about the things that are related to athletics and activity, but also the other things that are part of their anticipatory guidance.
Dr. Mike Patrick: I think from a family point of view, the perception with these visits, sort of the thing that's first and foremost on parent's mind is, is it safe for my child to participate in vigorous activity and athletics? And especially as there's more awareness of sudden cardiac death for student athletes.
And we have AEDs in places where kids are playing sports and performing. One of the things it does is a part of this exam is cardiac screening. So just tell us what you do when you see student athletes before they're participating? What kind of heart exam are you going to perform? And can they expect their primary care doctor to also perform?
Dr. Tom Pommering: Yeah, actually it's not that hard. And the form for Ohio, the officials sports physical form that comes out from Ohio High School Athletic Association incorporates what's called the American Heart Association, I think it's now 14-point exam. And part of it is history and part of it is physical exam, but there are certain questions that we should all ask athletes to help us decide if they have risk factors for sudden cardiac death.
A few of those, I'll give you a couple of examples, have you passed out during or after exercise? Do you have chest discomfort or tightness during exercise? Does your heart race or flatter? Looking for arrhythmias. Has your doctor ever done a workup for your heart in the past?
And there are family history questions as well as far as family members drowning or unexplained car accident or having a sudden cardiac arrest or sudden cardiac death at the young age. There are key questions that aligned with the American Heart Association asks us to do and those are incorporated in the pre-participation form.
And the exam is pretty easy. It's checking pulses, listen to their heart whether standing, sitting, and squatted. Looking for stigmata that could indicate problems]. It's a pretty basic heart exam that anyone can do.
Dr. Mike Patrick: And I think, so kind of looking at the big picture of it, I mean, you're looking at family history. Is there anyone in the family especially young folks under the age of 50 who have had significant heart problems? And then, if there's anyone who's been in a drowning accident and a car accident that was unexplained, could they have a heart problem that caused them to drown or caused them to be in that car accident?
That's the reason that we would ask those things. And then, the medical history of that individual with regard to chest pain, dizziness, especially exertion or symptoms are going to be important and then, as you mentioned, physical exam. Stigmata, by the way, would be physical findings that go along with certain syndromes that could also have heart problems associated with those, for folks who may have not heard that terminology before.
And then, for a lot of parents, they're going to say, "Well, are you going to do an EKG?" Where you put the electrodes on and see what the heart rhythms look like. Is that something you do for every student athlete before they participate or do you select who gets that sort of screening?
Dr. Tom Pommering: Yeah, that's another good question. It's been hotly debated in cardiology and sports medicine societies for a while. But I think right now the overlying opinion is that, no, we don't need to do mass screening for ECGs or EKGs also known as for sports.
There may be pockets of institutions out there doing that. They maybe a rule for certain collegiate athletes or sports where you might consider doing that or there are instance of certain cardiac diseases or higher. But for the average person, the history and the physical exam screening should suffice and EKGs aren't really generally needed.
Dr. Mike Patrick: And we have to keep in mind that the EKG or ECG is a snapshot in time of the electrical activity of the heart while you're hooked up to that monitor.
And certainly, if you're having symptoms with exertion and if you have chest pain or dizziness, light-headedness, you passed out, especially while you're actively exercising or immediately after you exercise, you need to see a cardiologist, if you have any of those symptoms. And so, that's the most important thing rather than the EKG.
And EKGs not only can give you a false sense of security but then you can also have sort of false positives of the EKG, that can then make everyone think there's a problem when there's not. And then kids may be held out of sports in fear of that. So, it's kind of a complicated thing and the best thing is if you're worried about the student athlete's heart is to get him in to see a cardiologist. Would both of you agree with that summation there?
Dr. Simon Lee: Absolutely.
Dr. Tom Pommering: Yeah. The other thing is you have false negatives. I think people get lulled into thinking an ECG is going to screen for everything. And there are other causes of sudden cardiac death where the ECG is not going to screen properly for.
Dr. Mike Patrick: Yeah, absolutely. Dr. Lee, I want to bring you in. So we've been talking all about cardiology stuff, but sort of free referral. So with this idea that we're concerned about student athlete's heart are based on family history, their past medical history or the exam. Then we're going to send them on to see a cardiologist.
Now, with the SARS-CoV-2 virus and COVID-19 disease, we're hearing more and more about the possibility of something called myocarditis, where this virus can affect the heart. Tell us what is myocarditis and how is that associated with COVID-19?
Dr. Simon Lee: So myocarditis is sort of a general term and it just refers to the inflammation of the heart muscle, which is the myocardium. And there's actually a lot of different reasons that can cause myocarditis, but one of the big concerns is that there's some emergent data now that SARS-CoV-2 or COVID-19 infection can actually predispose someone to having some sort of heart issue.
A lot of that information is in adults and it tends to be the sickest adults, those who are hospitalized, who are sicker and long stays in the hospital. But there's definitely some newer emergent data looking at how those adults are doing once they're out of the hospital.
Some of the papers are showing that they have pretty significant incidents of some sort of evidence of myocarditis on MRI. And then I think, we're also getting a lot of emerging data in athletes now that is suggesting that there may be some myocarditis after COVID-19 infection as well.
Dr. Mike Patrick: So there's some studies that are emerging primarily in adults where we have after an infection of COVID-19 where we have this inflammation of the heart muscle. Do we know is this directly from a viral infection of the heart? Or is it the person's immune system that then causes some heart damage as it's fighting the infection? Or maybe a combination of both? Do we have a sense of where this is coming from?
Dr. Simon Lee: So I don't think anyone knows for sure right now but there's definitely studies, in autopsy is actually a patient who passed away from COVID-19. There's relatively large adult study and these were older adults but those who passed away not from a heart problem. And their primary cause of death was something respiratory related.
And on autopsy, they found I think it was over half of them had evidence of the virus in their heart muscle. So not direct evidence of myocarditis but certainly evidence that there was SARS-CoV-2 in the heart muscle.
And then, there's also some evidence with kids as well. Initially, the thought was that COVID-19 didn't really affect younger kids, teenagers. But now, with the emergence of what they call multisystem inflammatory syndrome in children or MISC, they're finding that while it's rare, and it doesn't happen often, that some kids do have a very profound autoimmune reaction to the virus, or at least that's what the thinking is currently.
And that majority of these kids actually do have heart involvement and this tends to be three to four weeks after viral infection. That's the leading thought is that this is some sort of immune reaction that the body is having to prior infection.
And so while there's a lot of studies going on to try to figure that part of it out what makes this person different than that person, why did these sibling get MISC but the other sibling who presumably have COVID-19 didn't get it, there's a lot of studies trying to figure that part out. But I think that it's not really clear because we're seeing evidence of both. We're finding virus in the muscle but we're also seeing significant heart effects in younger kids, who presumably were infected with the virus weeks before.
Dr. Mike Patrick: Most of these studies and what we're finding it are, I would assume, in people who have fairly significant disease. So if your respiratory portion of COVID kills you and you have an autopsy and then you find that there's evidence of the virus and the heart muscle, then is that the same as someone who has a mild illness? Can we then make that lead that there also going to have the virus in their heart muscle? Or does it take significant disease for that to happen or we just don't know?
Dr. Simon Lee: I think we just really don't know at this point. I think one of the things that was really alarming to people was this one study out of Germany, that this was the one causing a lot of headlines and a lot of debate. They look at 100 adults and not terribly older adults, they're in their mid-40s about, but this was a mix.
Some of them were admitted to the hospital with mild disease. Some of them are just at home. They had mild symptoms and just quarantine at home. Significant number of them were asymptomatic, meaning they just didn't have any cardiac symptoms. And yet when they get an MRI, or about 60% of them have evidence of myocarditis. So, I think that was the initial one that really caused a lot of alarm.
Dr. Mike Patrick: What about other viruses, especially other respiratory viruses such as influenza, adenovirus? We see coxsackievirus. Can this also do that? And maybe they do, we don't know because we're not doing cardiac MRIs on kids who have the flu or have coxsackievirus.
Dr. Simon Lee: No, I mean, that's a great point and that's something that comes up very often. And we know that that does happen. Myocarditis is not new. This is something that's been around for a while.
But I think what makes it more concerning from our standpoint is just that there's some studies that are sort of indirect. Because you're right, we don't MRI everybody for flu or coxsackie, but just looking at some indirect evidence in hospitalized patients, some of the studies showing, and again in adults, but showing hospitalized adults with COVID-19, up to 20% of them had evidence of troponin leak and some sort of cardiac involvement while admitted. And again, the sickest adult, but while admitted. And then in comparison, they look at adults who are admitted with influenza, only 3% of them had troponin leak.
I think the big thing with COVID-19 is we just don't know but it seems like at every turn, it just seems to throw us another curve ball. And people are doing a lot of things that if you just went by conventional wisdom, proning patients, accepting adults who are with SATS in the 70s, stuff that would be someone would say it was crazy.
Just a year ago, I think we are learning that this is just how the virus acts. And so, I think we just don't know and our feelings is that they're just the way COVID-19 is reacting, how unpredictable it is. I think it's hard to say that we can treat this like any other virus.
Dr. Mike Patrick: And when we don't know something, I think caution is the better part of our, especially as we think about our children. And we'd sort of rather overdo things and then as we get down on the road look back and say, "Oh, we didn't really need to do all those things."
But the decisions that we make now based on the fact that we love our kids and we want them to be healthy, we want the best for them, it's probably better to overdo things at this stage until we do know more. Would you agree with that?
Dr. Simon Lee: Yeah, exactly. When you're talking about something like sudden cardiac death or some sudden cardiac event, those are things that we really take seriously. Obviously, we all do. And so that's part of our cautiousness.
Dr. Mike Patrick: So, what are the symptoms of myocarditis? What would make you think that could be going on after a COVID infection?
Dr. Simon Lee: One of the issues of myocarditis is that the symptoms can be very non-specific. You can have pretty obvious symptoms like chest pain, pretty significant chest pain actually. But some of the other symptoms are pre-nonspecific. Just some fatigue, shortness of breath or dyspnea on exertion. You just get short of breath or can't catch your breath very easily compared to what you're used to. Palpitations, skipped heartbeats, and just sort of any exertional symptoms, muscle aches, myologies, things like that. So they can be very non-specific.
Dr. Mike Patrick: As we think about the heart, obviously chest pain, shortness of breath, exercise and tolerance, light headedness. But if you have an arrhythmia which can also happen with myocarditis, right, so a rhythm problem. So, you may have very mild symptoms but if you are exerting yourself, the electrical activity of the heart can suddenly have an issue.
And so that's really where this big worry comes from, right? Not necessarily they're going to have this really symptomatic myocarditis which usually develops over time and not suddenly. But one thing that we're really worried about is student athletes who might have myocarditis, but the symptoms are so mild that they don't know it. But then, they have a sudden electrical problem and they have a heartbeat that does not profuse the body and then that's where you can get sudden death of an athlete on the field, right?
Dr. Simon Lee: Correct. And the big concern is that if you think about it like when you get the flu and your muscles are achy or your body is aching, what do you do? You rest. You don't pick up anything heavy, take it easy until you feel better. And the problem with the heart muscle is that it just can't do that obviously. It's just got to beat and it's got to beat all day every day.
And a lot of the recommendations for official participation are if you have a diagnosis of myocarditis, then you're restricted from physical activity from minimum of three to six months.
And part of that is it is a little bit of an older study but it's frequently sided or pointed to. There was a study looking at mice and they actually gave them myocarditis. And what they found was that when the mice exerted themselves, I don't know if it turns in a wheel or how they figured that part out. But what they discovered was that the mice that were physically active, they ended up having more inflammation and more virus actually in their heart muscle on autopsy.
So, I think it sort of that idea that the heart muscle can't really rest. If it works harder, then it seems to make inflammation or swelling worst and also may clearing the virus more difficult or more problematic.
Dr. Mike Patrick: And one the early symptoms that we heard about like back in March when this was just starting is folks who would get an infection with SARS-CoV-2 virus that there was just this really impressive fatigue. You hear people say, "Oh, I would just be in bed for three or four days on end." Obviously, your immune system using up energy can cause fatigue.
But could some of those folks who've had some myocarditis that would cause that degree of fatigue and exercise and tolerance? There's no way to know without looking into it, right?
Dr. Simon Lee: Absolutely. We have no idea and we've seen a number of teenagers now who had COVID-19 and were coming to us for clearance. And really, the range of symptoms is very varied.
And some of them, I mean, I can just think of a couple off top of my head who one athlete was a one month out from infection, the other athlete was two months out from their infection and they were still having symptoms, symptoms of shortness of breath. They weren't able to get back up to their typical activity level without getting short of breath.
And fortunately for them, they have the full work up, MRI, everything was normal, but you can still have some pretty significant symptoms after the fact. And I think we don't know if athletes, they were kind of taught to just push through it, grind through it. It's very difficult for them to report any sort of symptoms or have any come to medical attention for something like this until it gets pretty bad.
And so, that's the big question is, okay, let's say you had COVID-19 in March and then you had severe symptoms. But what does it mean for you now? Could you have had myocarditis or was that something related to the lungs, right? Which is also the other big area that I think people are having residual symptoms from.
I mean, we really just won't know unless we are looking to see what is actually going on. And I think there's some data in college athletes, which I think is a little bit of a different ballgame, obviously. This is a multimillion, multibillion dollar industry. Some of these guys are going pro.
There's a lot of just resources available to these athletes. And they're finding myocarditis in this college athletes. There's a prepublication from Vanderbilt, not a huge number but they found it. They found couple of athletes that had some abnormal cardiac MRIs.
Dr. Daniels was giving interview for the New York Times and he mentioned they were looking at it. And there was about 15% I think is what he said in the article of athletes with myocarditis and it's there. We just don't know what it means for high school or younger kids.
Dr. Mike Patrick: And here's I think where the real difficulty with all of these is that some of the symptoms that we see with COVID-19 can mimic the symptoms that you see with myocarditis. But it doesn't necessarily mean myocarditis is there. But you could also have mild disease and still have myocarditis.
So, you just really can't go on symptoms alone to try to figure out if this is going on. And since it can happen even in mild disease, it's going to make it even more important that we identify all kids who are infected with COVID-19 even if they have mild symptoms.
And so that really brings me to my next question. And Dr. Pommering, what are the recommendations for screening student athletes for COVID-19 so then we can go on to say, "Well, now do we need to worry about myocarditis in these kids?" Should all student athletes be screened for the disease? What do you think?
Dr. Tom Pommering: For COVID-19, you mean?
Dr. Mike Patrick: Yeah.
Dr. Tom Pommering: Yeah. Just because of the close contact nature of sports, we don't want kids spreading it to their teammates. What we're seeing most of the schools and the clubs that are actively competing and practicing, they're following the state and the county health guidelines or the CDC.
The kids are self-screening or they're being actually asked about symptoms on regular basis. If they have a fever or feel bad, they're supposed to report. And then they get quarantined and so on.
So, I think it's the same as they do for all the students that are coming together in close contact. Otherwise, when students are actually practicing, if they're not actively exercising, then they're wearing mask. They're staying six feet apart. They're doing all the other things that we normally should be doing with the exception when they're actually competing.
So it is tricky to see if there's a safe way to do this and it is a big experiment right now.
Dr. Mike Patrick: So, certainly if you have symptoms suggesting that you could have COVID-19, obviously, you want to get tested right away. And if you have a significant exposure. And last week, we talked about getting back to school in the era of COVID. So we did talk what is a significant exposure and those kids testing.
The kids who have no symptoms at all are the difficulty because in a perfect world, you just test everybody once a week and then you're not identifying them easily. But we don't necessarily have that kind of testing capability all around the country right now. Some areas may be able to do that and others not. So it really comes down to listening to your own local public health officials and each individual schools.
And it makes it confusing when some parts of the country are doing things differently than other parts but it just depends on what's available, and also how much of the disease is in that particular community. So, it's not a one-size fits-all answer, right?
Dr. Tom Pommering: Absolutely. I do think that the school superintendents and principals, and athletic directors and coaches are all interested in doing the right thing and to follow the guidelines from their health department. Because they don't want the whole thing to come crushing down any more than anybody else does.
Dr. Mike Patrick: Absolutely. So let's say now that we have a student athlete who for whatever reason gets tested and they have a positive test for COVID-19, whether it's they're asymptomatic or have mild symptoms or they have severe symptoms. How do we then, Dr. Lee, go about screening those student athletes for myocarditis after they have been identified as having a positive test?
Dr. Simon Lee: I think that's really the big question is we're saying that you can have mild symptoms and you could have myocarditis. We're saying that the symptoms of myocarditis can be very non-specific or very vague.
And one key thing about is kind of particular to us in Ohio is that actually, there was a governor's order talking about return to play for COVID-19 athletes. And it specifically does mention that if you have had COVID-19, whether you're asymptomatic or not, they should have a medical exam and specifically to evaluate for myocarditis. And it does explicitly say myocarditis.
I think those are the things that we're dealing it and we're trying to figure out what's the best way to evaluate these athletes in a timely fashion. Because, absolutely, you don't want to keep kids who can be playing out for longer than they need to but also just making sure that it's safe for them to return to play.
And so, we got together. We have been working with our sports medicine colleagues about trying to find the best way to handle this. And then, we have talked a little bit within our Heart Center group and a couple of smaller group people who were invested.
And honestly, it all kind of came back to the same thing, which is that if we're talking about myocarditis and that's the government's order specifically states, really, the only reliable way to test for that is through cardiac MRI. And so then, the question became, well, who gets the test, right? You can't just get this at Walgreens mini-clinic and it's also something that takes about an hour. The exam itself takes about an hour. So how do we figure out who to offer to this to? Who is the highest risk?
And when we look at it, there really was no way to know. Just looking at some of these studies from college athletes, so then Vanderbilt study I mentioned and some of the information that's out there about what Dr. Daniel has been talking about. The Vanderbilt study anyway was pretty explicit. They said echocardiography, EKG, bloodwork was not helpful.
And we got a similar sense from Dr. Daniels also. We haven't seen that data. That data is still being looked at and peer-reviewed and all of that, but that's kind of what they found. That has been our clinical experience, sometimes a kid will come in, we have no idea. Somebody sent a troponin for some reason and it's sky high, and you would have no idea.
Or like somebody comes in and they have chest pain and their EKG is sort of non-specific abnormal. But then you check your troponin, it's negative and then you do an MRI and it's positive.
I think the only real way to evaluate properly from myocarditis is with the cardiac MRI. And the funny thing is we talk about what kind of screening test we can use, EKG, bloodwork, echo. Well, if any of those are positive, then the patient is going to get an MRI. They make you suspicious for the diagnosis but the end result is going to be an MRI.
And so we're trying to balance. We also don't want to have false positives. And like Dr. Pommering mentioned, with EKGs, not only is there the concern with false negatives where you just get a false sense of reassurance. But you can also a false positive, some sort of borderline or non-specific findings that could take an athlete out of play for however long it takes to fully evaluate them.
That's certainly a significant number of athletes from screening EKGs also. So, I think that's how we all arrive at this conclusion, that if we're going to evaluate for myocarditis which is what the concern is, which is what the preliminary data suggest, and which is also what's mentioned in the governor's order, then MRI is going to be the best and most efficient way to do it.
Dr. Mike Patrick: So this really I think puts primary care, pediatricians, family practice doctors really in a bit of a bind. Because, ultimately, the parent is going to be bringing in this form to sign because at least here in the state of Ohio, you have to have a doctor sign a clearance form after you had a COVID-19 test that's positive.
And so what you're saying is that lack of symptoms is not really a good way to say you don't have a myocarditis. You could have a normal troponin. You could have a normal EKG, chest X-ray, the typical things, really normal exam, and you still could have myocarditis that could cause a rhythm problem that could result in sudden death of a student athlete. Am I overstating that?
Dr. Simon Lee: No. that's absolutely correct. That's the conclusion that we came to after talking about this a couple of times.
Dr. Mike Patrick: Now in the adult world, how does that compare with what the recommendations are for adult athletes? Now, I'm not talking about NBA players and professional athletes, but the adult sports medicine, adult cardiology world, is this also the direction where this is going? Or are we being more cautious and careful because we're talking about people's kids?
Dr. Simon Lee: I think that there's a number of guidelines, or recommendations, I should say, because this is all sort of expert opinion at this point. But there are number of adult recommendations that do seem to stress more testing, more of a concern for myocarditis. I think they typically break it down mild or asymptomatic. They say consider an EKG. Although they do acknowledge that you can't necessarily rule out myocarditis on an EKG but that's one part of it.
And then, on the other part of it, if you have moderate symptoms or certainly if you're hospitalized or have more severe symptoms, they can advocate for full workup, bloodwork, echo, EKG and including MRI.
And so, I think our feeling is just that we just don't know enough about is it okay for us to say mild or asymptomatic people don't need any sort of testing? We just feel like the EKG is not going to be helpful and could be harmful.
And so, we're trying to figure this. We're trying to answer this question now. And so who knows, maybe in two months, we'll say, "Hey, we have looked at this. We have looked at 50 athletes who had mild symptoms or asymptomatic COVID infection and none of them had myocarditis."
And so we'll know. And then, I think we'll be able to make a thoughtful recommendation to say if you have mild or no symptoms from COVID-19 and you're an athlete, you really don't need any sort of evaluation unless you're symptomatic. But I think we're just a little cautious about getting right to that conclusion without really knowing.
Again, it's a little difficult with some of these conversations just because some of the studies we talked about haven't been peer reviewed and published yet, but just with some of these pre-publication, some of the information that's being reviewed right now that's emerging, it does paint a concerning picture. Maybe we're not right to say no.
Dr. Mike Patrick: Yeah, absolutely. And I think all of us, including parents, are witnessing science happening. And so a lot of times, it comes across as the doctors don't know what they're doing. They say this and then a couple months later, they say that. But that's what we would expect with science, as we do learn more and our studies are peer-reviewed and larger studies then verify the information found in smaller studies.
And I mean we're really witnessing science history in the making and we want to protect our kids in the midst of this. And so, we may be overdoing it to some degree but on the other hand, if we save one child's life, are we really overdoing it? This is where we are right now.
And I think because we have folks in this audience, in fact, 80% of our audience is outside the state of Ohio for this podcast, there's going to be areas where a cardiac MRI is just not going to be available. And there's also going to be instances where that cardiac MRI, the heart MRI is going to be very expensive and we have parents who have high deductibles. And then are they going to have to pay that out of pockets?
So how do we then make decisions based on what resources are available? And each family is in a different situation. So this idea of shared decision making, talk to us a little bit about that.
Dr. Simon Lee: Shared decision making, I'm the director of the Coronary Anomaly Program, and so that ends up being a very important factor in terms of discussing coronary anomalies with athletes.
I think the point of shared decision making is to say that we know that there's some risk but we don't know what that number is. And I think everybody has a different, I don't want to say risk-tolerance, but I think everybody has a different sense of how important participating in athletics or not participating in athletics are to them.
And so shared decision making is really going over those things. You kind of talk about this is what we know about the risks, this is what we don't know, which I think is equally important, and this is what we can do.
And so just using that anomalous coronary analogy, I think this is kind of an interesting thing, too. Because the thinking of anomalous coronary areas has changed pretty dramatically in the last five, ten years.
You used to be restricted from all sports until you had surgery for any kind of coronary anomaly. And this has kind of been the hallmark for what I think we're trying to do here. As we went from there and then we start to really say, "Hey, is this the right thing? Should we be treating all of these the same way? How can we figure this out?"
And so, I think using that as an example, we started saying, "Hey, we need more data. We need more information." We need to look and characterize how this coronary anomalies look. We need to do better imaging of them. We need to figure out how many of these kids have symptoms with it, how many don't, how many go to surgery, how many don't, and what happens in all of those cases.
In that case, we got more information and one of the changes that occurred due to that was that when you're having anomalous right coronary artery, that used to be hard to stop. You need surgery before you can play.
But that was updated. That was updated a few years ago to say, "You don't have to have surgery to play because we're not sure what the risk of sudden death is or sudden event." It's not zero, we know that, but it may not be high enough for surgery is indicated or the risk benefit of that outweighs having an anomalous coronary and playing.
And so that's where the shared decision making comes in. You just acknowledge what you know and what you don't know, what we can do. And then, it does come down to an individual decision.
I don't think we know enough to say, "Hey, you definitely can't play because your child will for sure have myocarditis. And they for sure will have an event, like we just don't know. And that's what we hope to find out by making our recommendations for MRI. We hope to actually get some information and data to say, hey, this many do have or this many don't. These folks should get MRI, these folks don't have to."
But that's part of what shared decision making is, just letting people know what we're thinking and to try to help them make the correct decision for that athlete, for that family.
Dr. Mike Patrick: And so, it's really just walking that road with them and talking about the benefits of doing something, the benefits of doing nothing, the risks of doing something, the risk of doing nothing. Just looking at all the various possibilities of outcomes in this honest of a way as you can, based on what we know now.
And the end decision of any particular family may be different from one to another. It doesn't make it right or wrong, as long as all the known facts are there to sensitized through. And that's not a conversation that you can have in five minutes in the exam room, right? I mean, you have to be able to spend time with the family and talk about that.
And I'm hopeful. I haven't seen what one of the State of Ohio forms look like for return to play, but I would hope that there will be something in there about how you've talked to the family. I mean, because from a primary care pediatrician's point of view, like to clear them when none of us know what the risk is. And if that's the case, I wouldn't clear anybody because I wouldn't want to take that risk.
So hopefully, there's a way to say that there is a risk and if you decide to return to play like you at least know what the risks are if you do decide to do that. Have you seen these forms, either of you, guys?
Dr. Tom Pommering: Before I answer that question, I want to just state the obvious real quick. One is that this has been a really difficult year for everyone in the world and people are really desperate to have some normalcy in their lives. And athletics and physical activity's definitely one of those things.
This is truly is a novel virus and it's doing things that we've never seen and there's a lot of uncertainties about how to approach folks with this illness. But on the positive side, I don't think there's ever been an illness in modern times that's had the amount of resources devoted to studying it and learning about it and trying to know what the best thing to do is.
So I think that confusion about different guidelines or recommendations, definitely, we feel the patient's confusion on that, but by understanding this better, we can really make better recommendations for folks that are more evidence-based. And that will ultimately end up in making people safer and healthier.
So, we feel that confusion that parents and kids are feeling, but let's just hang in there. We're trying to figure this out as fast as we can.
As far as return to play, the State of Ohio does not have a specific form that needs to be filled out, but there are recommendations out there on how to do that. So once an athlete was deemed ready to return to their sport, very similar to what we do with concussion, we don't just throw them back in the field and say good luck. They have to go to a phase of acclimatization or increased activity that's supervised, so we know that they're truly ready as we stress their bodies and work out harder and harder.
And there is published guideline out there that takes these athletes through a period of maybe 10 to 14 days where each phase, there are six phases right now, and each phase increases their cardiac demand a little bit more. And while they're doing this, they're supervised, hopefully, by athletic trainer or someone else or some other medical professionals. So we can screen them for those symptoms that we look for, for myocarditis or other cardiac conditions, to make sure that they're able to continue to increase their physical activity to then eventually back to their sport.
There's no national guidelines for this. There's a paper out that suggest the way to do it. And I think a lot of institutions around the country and in Columbus in the State of Ohio from just our querying are using this or something like it. And it seems like the important thing to do right now.
It allows us to sift out kids who are deconditioned from being quarantined and from being sick from the ones that are truly not able to get back to the fitness that we would expect over the couple of weeks.
Dr. Mike Patrick: So from the primary care physician's point of view, if a student athlete has COVID-19 and the family comes in and say, "Hey, they need to be cleared to play", a good referral would be to sports medicine folks to help guide them on return to play in a safe way. Is that correct?
Dr. Tom Pommering: Yeah, I think once they've sort of received initial clearance in terms of, "Hey, you're no longer infected" or maybe they have seen Simon and they work them up and said, "Hey, you don't have myocarditis," and they're ready to return back to the field, if we know that they had COVID-19, we're going to take them through this our acclimatization or this guided or graded return to play that will be supervised.
Dr. Mike Patrick: Yeah, that makes sense.
Dr. Tom Pommering: Just to kind of answer that even more specifically, I think most of the schools in the states or the city here are following this type of guideline. Their athletic trainers are supervising this with their student athletes.
Dr. Mike Patrick: So how then here in Central Ohio, Dr. Lee, are we getting kids in for cardiac MRIs after COVID infection if they're looking to return to play? How do pediatricians make that contact with you, guys?
Dr. Simon Lee: They need to first stay in quarantine for 14 days from their symptoms. So that should be taken care by the Ohio Department of Health. We've got a couple of calls like four days later like, "When can I come in?"
So I do want to start with that, that even before considering any sort of return to play and I believe these are sports medicine guidelines, so just 14 days from your symptoms, 7 days asymptomatic. Some folks are following but some of these athletes are not, so I do want to stress that part.
Once they meet the clearance and, again, I would just certainly speak to the PCP or their medical home first. Typically, what happens is that a referral goes to Cardiology. And we have the system set up so that we have a group of great hardworking nurses, the triage nurses, who will field the referral.
And they have a screening questionnaire that we've created, that Dr. Nandi created from Cardiology, and basically goes through when were they positive, what sort of COVID-19 related symptoms that they have? Are they restricted or are they not restricted? And if they are having any cardiac related symptoms or not.
And depending on what that screening questionnaire yields, certainly, if somebody's having some sort of cardiac related symptoms such as palpitations or syncope, passing out or almost passing out, then those get sort of routed right to one of us. There's a handful of cardiologists that are helping deal with these patients, myself included. And so we would try to get those athletes in the next day or two just to make sure there's a higher concern for myocarditis or possible myocarditis in those kids.
For those that are not symptomatic or minimally symptomatic, again, our great triage nurses who have been working so hard will go through some of the thought process in terms of, "We're concerned about myocarditis or we want to evaluate for myocarditis. The best way to do that is cardiac MRI. Would you like to be scheduled for an MRI?"
And so, if the family is interested or the family is symptomatic and should get it, then the nurses from there are actually contacting our radiology department. And we are actually just getting those kids scheduled as soon as they can. So far we've had, I would say almost 30 to 40 referrals and that most of those are being scheduled within a week of when they're coming through.
There's a little bit of new ones. Our general Nationwide Children's Hospital policy in terms of quarantining and when patients can come in after COVID-19 infection is different from the CDC recommendations. For any patient who is coming within 30 days with their positive test, we're recommending full airborne precaution or negative pressure.
So that part, we've been working around that part and the Nationwide Children's Epidemiology Team and everyone had been really helping us out trying to make this work.
But for the most part, once the screening intake happens from the triage nurses, we are either scheduling those kiddos to have an MRI at Nationwide directly or we are for some of the older kids and especially some of the ones that are in that 14 to 30 day window, if they're 16 or older, then our colleagues at OSU are helping us out and also scheduling some of those kids there.
And then once the MRIs happen, we follow up with it and then we have a telehealth visit with the family to go over the results. If the MRI is positive, then we would switch that over to an in-person visit just to have a more in-depth discussion on what that means. And then, you have the workup that needs to happen.
But once the MRIs happens several days later, we schedule a telehealth visit just to let them know. If the MRI is normal, then no evidence of myocarditis, then we tell them just, "You have no evidence of myocarditis. There's no reason from a cardiologist standpoint that you can't go back to your graded return to play."
For those families who declined the cardiac MRI, we have a telehealth visit as well just to go over to some of the shared decision making. And we just talk to the families about why we're recommending a cardiac MRI, what the thought process is and some of the things that we've found so far, or not found. And then, let the family make a decision from there.
And unfortunately, if they decline the cardiac MRI and just partly because of the specificity of the governor's order, after telehealth visit, we let them know, "Hey, there is some risk of myocarditis. We don't know what it is. Without an MRI, we won't know."
Then at that point, if the family declines the MRI for whatever reason, then unfortunately, we have to let them know that we can't really evaluate you for myocarditis. So we can't provide that specific cardiac clearance, meaning, we can't say that there's no evidence of myocarditis.
Definitely, this is a lot of confusion from the primary care providers, from the families, and I think this does raise concerns about access whether people are able to get the cardiac MRI for either financial or access reasons. And so we are working with hospital leadership to try to find some ways to make this happen, so we don't end up with any sort of disparities in access.
The Heart Center leadership has been really supportive of this whole endeavor. We're working really hard to make it so that we can make it happen for everybody who wants it or is interested. And Radiology also has been fantastic in helping facilitate all of this as well.
Dr. Mike Patrick: At the end of the day, we're just trying to do the right thing and really make sure that kids are safe and return them to play in the safest way possible. I do want to mention because we have so many people who listen in other parts of the country that really talk to your child's doctor and find out what resources are available in your area, what recommendations your local children's hospitals have.
It may vary from one place to another. And I think it will start to solidify and there will be more universal recommendations when we know more. And that just takes some time to let science kind of work through these things.
A couple of things that I wanted to mention real quick since this is podcast for parents. You mentioned anomalous coronary arteries. So that's a different condition where the arteries that feed oxygen and nutrients to the heart aren't in the place they're expected to be and that can cause some sudden heart problems, right, Dr. Lee?
Dr. Simon Lee: Right, right. It's a medical finding that you're born with, so not something related to COVID-19 and yeah, exactly.
Dr. Mike Patrick: No, but it was a great example of how that shared decision making and those kids who are born with coronary arteries that can make it more dangerous to play. But of course, having open heart surgery can also be dangerous and sort of walking down that path of risks and benefits and that shared decision making, I think it was really great example.
One of the thing I wanted to mention with all of these is we think about arrhythmias and sudden death in student athletes, the importance of having AEDs or those automatic defibrillators on hand. And that's something that parents can really be advocates in your local school district. Wherever it is that your student athletes are playing, do they have AEDs available?
Not only they're available but do people know how to use them? And so, I imagine that you both would be advocates of making sure that those devices are available and especially now with this risk and with the risk of myocarditis that maybe isn't diagnosed. And then, there is a sudden arrhythmia if you have a student athlete who drops, you want an AED available, right?
Dr. Simon Lee: Right. And not just available, but people know where it is, it's accessible and know how to use it. And regardless of what we do restricting folks saying that you need to rest for three to six months, we don't know what the long-term effect of this is going to be.
And really, the bottom line is we're trying to prevent something happening, but nothing is a 100%. And really, if something does happen, if there is an event, the only way to save that person's life is going to be within AED. And time is muscle, they say. So the quicker you get it on them and the sooner you're able to defibrillate them or give them a shock, if they need it, is the way to actually save lives and prevent any events from happening.
Dr. Mike Patrick: And if a student athlete does have myocarditis, now this is going to be a much longer period of rest. And you're basically going to be under the guidance of the cardiologist and the sports medicine folks to get you back to play. But it's going to be a lot longer in terms of the heart needs to heal because there's a viral infection, and so your body just has to fix itself.
And then, very rarely this may end up needing a heart transplant. I mean, if it's really severe myocarditis, it's not getting better, which again would be the exception, not the rule. Most of this once you find it, it's just a long period of rest to let the body heal, right?
Dr. Simon Lee: Right. You can have the acute myocarditis. There definitely are different flavors. There's certain flavors that kids present very sick to the hospital and almost looks similar to what I mentioned earlier with MISC, where you just come in very sick acutely ill. And your heart is just not working well at all, your heart muscle is very weak. So there's that kind of myocarditis.
Then there's the acute myocarditis, which typically happens soon after whatever the end result is, whether it's a viral infection or what have you. And that's what we're trying to help recover is with the rest. You try to let the heart muscle recover, the inflammation, the swelling to go down by resting for three to six months.
And then a small percentage of those people with myocarditis or acute myocarditis do go on to develop what we call chronic myocarditis. And those do eventually either, well, they do eventually develop heart failure. And some of them do end up needing to get heart transplants.
Dr. Mike Patrick: But again, the exception, not the rule. It's rare, but...
Dr. Simon Lee: Small percentage. And that's the other question to athletes too, right? I mean, we don't know what percentage of these. I mean, anyone, athlete or not, we just don't know if COVID-19 or SARS-CoV-2 has a higher predilection or puts you at increased risk for getting chronic myocarditis and getting some sort of heart failure down the line. That's one of the other unanswered questions, which I think there's more attention to it in the adult cardiology world, just because there's so much COVID-19 in adults and they get so much sicker. But that does certainly an active question as well.
Dr. Mike Patrick: Fascinating conversation. And based on what we know as of today, September 11th, 2020. And so our knowledge about this is going to probably change to some degree.
And as we know more and if the recommendations do change, then we'll have you guys back and we can kick it around a little bit more because I don't think this is the end of the story. But we definitely wanted to get the word out.
And when, you look even at college football and you see some conferences are doing one thing, other conferences are doing something else, there really is not necessarily national consensus on any of these because of the emerging data and because different people are going to interpret things a little differently.
But there's going to come a time when it sort of does all come together as more studies and larger studies, better designed studies are available. And this is just again, this is science as it happens and all of its ugliness but the necessity of it. And this is how we ultimately figure things out. It just takes some time.
For folks who would like to know more about the Sports Medicine Program here at Nationwide Children's Hospital and the Heart Center at Nationwide Children's, I will put links in the show notes so you can find out more about those programs.
But in the meantime, Dr. Tom Pommering, and Dr. Simon Lee, thank you both so much for stopping by today.
Dr. Simon Lee: Thanks for having us.
Dr. Tom Pommering: Yeah, thanks, Mike.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Tom Pommering, sports medicine physician at Nationwide Children's Hospital and Dr. Simon Lee, cardiologist with the Heart Center at Nationwide Children's Hospital.
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