A Conversation With Dr. Josiah Peñalver and Dr. Matthew Studer About Pediatric Chest Pain and COVID-19

We have been seeing an uptick in the number of youth coming to the Heart Center for chest pain over the last several months and more questions than usual about chest pain from PCPs. We asked Dr. Josiah Peñalver and Dr. Matthew Studer, pediatric cardiologists with the Seattle Children’s Heart Center, why more kids are experiencing chest pain lately and what information could be helpful for community providers who are seeing these patients in primary care. Here’s what they had to say:

Matthew A. Studer, MD

Dr. Studer: Chest pain is certainly a common referral we encounter in our teenage patients. I imagine it’s compounded recently by concerns about COVID-19, deconditioned children, anxiety, concerns about the vaccination, etc. A few important points I think are always worth remembering are the following:

1. Providers should remember to always follow the AAP pre-participation evaluation and ask important standardized questions when taking their history (see: history and physical exam forms).
2. We are absolutely seeing more kids with nonspecific exertional symptoms that are a part of a child’s deconditioned state. Many kids haven’t participated in organized sports over the past two years, resulting in expected body aches and pains. Unfortunately, this can sometimes be hard to decipher as noncardiac chest pain.
3. The physical manifestations of anxiety and stress include chest pain and should be teased out with a focus on behavioral health issues.
4. Cardiac causes of chest pain, even in the COVID era, thankfully remain rare. But providers need to continue to be on the lookout for red flags such as severe pain during exercise, syncope during exercise, and chest pain days to a week after the second dose of the COVID-19 vaccine in the teenage/young adult age range.

Josiah Moises Penalver, MD

Dr. Peñalver: I agree with all those points. I would add that there is a lot of community concern specifically about post–COVID-19 vaccine myocarditis and that has prompted an increased number of referrals. As it relates to post-COVID-19 vaccine myocarditis, I would note:

1. Post–COVID-19 vaccine myocarditis is rare.
2. In order to diagnose it, a patient who has had a recent COVID vaccine and develops chest pain should talk to their PCP first, and if the symptoms are thought to be consistent with cardiac chest pain (based on the description of the chest pain), the next step is checking a troponin level (a chemical unique to heart cells which is elevated ifthere is cardiac inflammation).
3. If they are diagnosed with post-vaccine myocarditis, the ER or pediatrician will involve cardiology to help with the diagnosis and workup.
4. Most patients diagnosed with post-vaccine myocarditis are treated with ibuprofen and make a complete recovery without evidence of long-term cardiac injury. Often they spend a night or two in the hospital while we monitor their labs.
5. Because of the known risks associated with COVID-19 infection and its impact on the heart, we advocate all children — especially those with congenital heart disease — get vaccinated against COVID-19. The benefits of the vaccine far outweigh the risk of remaining unvaccinated.

I should add that Matt and I have given lectures on the post–COVID-19 infection return-to-sports guidelines, and Seattle Children’s cardiologists Dr. Yuk Law and Dr. Michael Portman are nationally recognized experts on myocarditis and COVID-19–related cardiac injury. The post–COVID-19 return to sports is a separate discussion but overlaps with post-vaccine myocarditis and the more general discussion about chest pain in youth.

Dr. Studer: I definitely agree with Josiah’s comments. We should all be champions of the vaccine for sure. All told, we’ve had just over 30 kids treated at Seattle Children’s with post-vaccine myocarditis. NONE in the 5 to 11 age range.

Question: The AAP early on noted that the incidence of myocarditis following infection was not known. But they also pointed to some initial studies suggesting a high incidence of myocarditis in people who’d had COVID-19, even asymptomatic individuals. How concerned should we be for kids?

Dr. Peñalver: I think those initial studies that reported rates of 40% to 60% were very early on and likely represented a selection bias since COVID-19 testing was so hard to come by. We were basically seeing and testing the sickest patients. We have certainly not seen these sorts of numbers now that we have more experience.

Post-COVID myocarditis is fortunately rare in kids. The numbers I have seen reported are around 450 cases per million infections, with a greater incidence in teenage males. That said, they can be very sick, often requiring admission to the intensive care unit. We treat MIS-C (multi-inflammatory syndrome in children) as a myocarditis-type disease, and those kids are restricted from sports for three to six months. The vast majority of kids return to sports once they have made a full recovery, and we fortunately have not seen much by way of long-term issues.

You are right that the concern in the community around both COVID myocarditis and vaccine-related myocarditis is fueling a lot of these questions from parents and pediatricians.

Dr. Studer: Yes, thankfully we’re not seeing any uptick in sudden cardiovascular death in children who have had COVID-19, as that would be cause for alarm. I do think we should be careful about incidence numbers with COVID myocarditis vs. COVID vaccine myocarditis. Some newer data just out in JAMA had post-vaccine myocarditis numbers in teenage boys (age 12 to 17) and young adult men (age 18 to 24) to be around 50 to 100 cases per million doses of vaccine (depending on the age range). The numbers are lower in teenage girls. There are almost no reported cases in children in the 5 to 11 age range. (Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021 | Cardiology | JAMA | JAMA Network )

I would not want people to infer that kids are less likely to have myocarditis with COVID-19 than if you get the vaccine. Children are much more likely to get myocarditis from the virus than the vaccine and they are much sicker. What we do know and should state is that the risk of complications from COVID-19, including MIS-C, are far greater than the risk of myocarditis following the vaccine.

This is why we, along with the AAP and many other governing bodies, are advocating that all age-appropriate children receive the COVID-19 vaccine. That said, if a child develops chest pain within a few days to two weeks after either dose, they should be advised to seek emergency care. And lastly, to Josiah’s previous point, we want people to know that the vast majority of these kids are recovering quickly with a fast resolution in their symptoms. Some, however, have residual MRI findings that we are following closely.