Pediatric cardiologist Lisa Arcilla, MD, FACC, presents a timely guide to identifying youngsters at risk for cardiac involvement from COVID-19. She discusses the demographics of MIS-C, offers UCSF’s system for care and follow-up, demystifies the stats on long-term heart complications and clarifies when imaging is warranted. Bonus: a look at myocarditis related to vaccination.
Thanks for giving me a chance to talk about this topic. I'm gonna talk as scheduled about the return to competitive athletics after covid. Um But also um as promised by Maria, I'm going to discuss um the um current reports about vaccine associated myocarditis. Well so I'm going to briefly go through the epidemiology of um pediatric covid and M. I. S. C. Um discuss the cardiac involvement in covid versus M. I. S. C. Um briefly, they'll go over our U. C. S. F. Management algorithms that we created in the covid um the UCSF pediatric crossed a covid working group um and then we'll go into saving safely resuming athletic activity and immunization updates. Yeah. So briefly, I just wanted to go over the UCSF. Covid experience has been really well documented in the enterprise dashboard. This is including both the adult and pediatric experience here. As you can see hospitalizations both in the ICU and non ICU patients in the adult population have significantly tapered off recently. This graph just shows a little bit of the pediatric population, um where we see that 10% of the 0 to 17 cohort with was hospitalized um and tested positive, but this includes a lot of patients who were getting pre um procedure testing and routine testing but were otherwise asymptomatic, which you can see in this graph over here. Um So in the pediatric dashboard, um, you can see that our numbers have really tapered off compared to our search that we had earlier in the year. Um we kind of have this bi modal distribution of hospitalized patients where there's this 15% and under one and then the 12% and the teenagers. Um but really every age group is um, you know, has a similar representation are numbers again, um in both symptomatic and asymptomatic are definitely tapering off quite a bit. And we've had a total of approximately 250 patients hospitalized with COVID-19. If you look at the Alameda County covid data, what we've got here is from the beginning of the pandemic, we had that kind of mini surge, the summer surge and then really the big surge happened over kind of the january february timeline. In the winter We had about 11,000 cases in Alameda County of COVID-19 and the UNDER 18 population. And if you look at the total cases over the previous 14 days, um not only do you see that we had our peak that has now subsided, but we've this data was pulled a little over a week ago. And since then we've gotten even lower, we've, with Covid case rates have now reached kind of the lowest levels seen during the pandemic, um and likely the lowest level seen because testing and uh is so much more accessible and abundant than it was back in the beginning of the pandemic. Okay, so, you know, vaccination um started rolling out kind of as we were coming off of our surge and really seems to have um been a very effective role out here locally. The UCSF dashboard also has the health equity dashboard and no talk about covid er M. I. S. C. Would be complete without noting the significant issues of equity that we've seen during this pandemic. If you look at this graph, the gray bars represent the patient population of the ethnicity listed at the top. And um if you look at our latin X and our black population, um if you see the gray bar here, it is far lower than the blue bar of patients that were tested and the orange bar who were tested positive and the red bar who were hospitalized. And so especially here at the Children's Hospital in Oakland, where a significant amount of our patient population is this latin X. And blacks population. We've certainly seen the disparities as evidenced by this graph here. If you look at the outcomes by language and the 9% of the population, the UCSF active patient population that has limited english proficiency, 30% of these were reflected in hospitalizations and so big discrepancies in our non english speaking latin X. And black patients. Right? So if you look at reports of M. I. S. C. As updated by about early May, um what we saw was 3700 and 42 cases of M. I. S. C. And 35 total M. I. S. C. Decks meeting the case definition, what's important to know about M. I. S. C. Is that it essentially has a bell curve distribution with a median age of nine years. Half of the kids with M. I. C. um were between the ages of five and 13 years 63% with the C. D. C. And also the studies that we're going to be going over about M. I. S. C. Um were patients who were hispanic or latin X. And black non hispanic. And that number has been pretty consistent about 60 to 70% across large studies. Um and there's been a slight male preponderance with 60% of reported patients being male. If you look at the M. I. S. C. Experience in California as reported by the C. D. C. We've got a lot of cases out here um and that happened um kind of in conjunction with our winter surge. We um have 300 plus in California, L. A. County alone reported over 150. Um And in our hospital the Oakland campus we've had about 40 cases of M. I. S. C. That we had hospitalized. Okay if you look at this graph from the CDC, what it's showing is that there's the temporal association between M. I. S. C. And covid cases. And essentially what happens here is that um you know somewhere between two and eight weeks after you see your covid searches, you see your M. I. S. C. Surge and the M. I. S. C. Is characterized by far more cardiac involvement than the covid cases. So typically um there's less respiratory involvement. G. I. Symptoms and um are more prominent in M. I. S. C. Neurologic symptoms are more common in older Children and their significantly higher cardiac involvement across all ages. Uh huh. This is a long term follow up data that was published in the Overcoming Covid investigation. And basically um what I was mentioning that the cardiac involvement in M. I. S. C. Versus covid is much higher. So cardiovascular involvement um in patients with M. I. S. C. This is comparing um 539 patients with M. I. S. C. To 577 with severe acute covid 19. And if you look at the cardiovascular manifestations in patients with M. I. S. C. It's about 67% versus 12% cardiovascular um in severe acute covid. Um And those numbers are even less in patients without the severe symptoms. Of course the things that we see most often are pericardial effusion, reduced, left ventricular ejection fraction. And um in M. I. S. C. In particular the coronary artery aneurysms and arrhythmia. Okay. Um this is just a review of how oh and initially reports um of cardiac advantage. Children was much higher in becoming covid trial which I just showed it was about 67%. And the further we extend the data the less we see cardiac involvement and it's thought to be that before july 1st the MSC patients were not the I. Slightly b treated with the I. G. Uh less likely to have received steroids and their cardiac involvement that we see as I mentioned. Left ventricular dysfunction, coronary artery aneurysms, conduction abnormalities also vasculitis, valve dysfunction and pericardial effusions. Um So this is just showing the um in one of the cases that we had just very mild left ventricular reduced ejection fraction was improved over the course of sorry improvement over the course of follow up um patients with pericarditis and pericardial effusion. So this is as shown in the previous slide we have a four chamber view here with the left atrium left ventricle. This patient has good systolic function but there's a rim of fluid around the left ventricle representing a pericardial effusion. And just showing that these typically improve and resolve pretty quickly. Um And just you know it's a small amount of circumferential pericardial effusion which is not affecting him dynamically affecting the patient just indicative of the inflammation, coronary artery involvement. Uh What we've seen is very similar uh mm hmm. Uh A new york uh uh a group. Um And this is the left main coronary artery and the left anterior descending. Uh And then the right coronary coming off the anterior really which was top normal with a Z score of 2.4 E. K. G. Changes that we've seen in M. I. S. C. Largely mimic that of myocarditis. And you'll see this E. K. G. Again when I'm talking about myocarditis because it really demonstrates a lot of the key findings. First thing that's pointed out here is low voltages diffuse lee in this E. K. G. The second thing that we see in this E. K. G is new onset heart block. Linkenbach can be considered normal variation, but in the setting of low voltages and T wave inversions um is a little bit more concerning. Typically when we see winky back as a normal variation, it's an athletes athletic teenagers with low resting heart rate and this is just showing the progressive lengthening of the P. R. Interval and then a blocked P wave. So the dropped beat that you got both winky bach T wave inversions in V. Five and V six. What's really important to know is that in pediatric patients prior to adolescence, um in V one through V four, T wave inversion is often considered normal variation and sometimes in black athletic teenagers inversion in B five and B six can be normal. But it is if seen is screening E K. G. It is definitely something that warrants additional work up and confirmation with an echocardiogram of normal ventricular function. Okay, this patient r E K. G and follow up six weeks later had normalized. This was one of the patients with M. I. S. C. Um uh and um mm Yeah. So briefly, I'm just going to go through the UCSF guidelines for evaluate resources. The Covid working group, we came up with the Emergency department algorithm for M. Sc and then Covid and MSC guidelines which were more focused on treatment. So essentially, you know, we got involved really early in these patients. Um So the clinical evaluation in the emergency department has shown here and anybody who's dynamically unstable if there was concern for um covid 19 or other sources of sepsis. Um There's often a role for the pocus echo which is essentially the point of care ultrasound performed by the emergency department which involves limited views to assess for ventricular function. And we often get involved just to confirm or deny what the emergency department is seeing on those as they help um triage those patients who have human dynamic instability. Otherwise if there's no evidence of shock, we still get involved pretty early with an E. K. G. And possible echo to assess for ventricular dysfunction, recurrent pericardial effusion, valve dysfunction um and coronary artery abnormalities as this can then impact our management. So these are pediatric Covid and M. I. S. C. Guidelines which is kind of an interactive website whichever you're hoping to learn more about. It has both acute covid 19 and M. I. S. C. Um and the anti coagulation guidelines for both and essentially you know the Mfc definition and the laboratory workouts are on this document and in our initial evaluation as I mentioned um we are typically getting an E. K. G. And eco pretty early on. And so all of these patients are plugged into cardiology from the beginning. Um We do an echo um pretty close to the initial management and the reason I showed this slide was just to highlight that the treatment of M. I. S. C. Is very similar to our management of both myocarditis and kawasaki disease. So we have I. V. I. G. Um steroids and low dose aspirin as prophylaxis for the potential coronary artery abnormalities Okay. During the hospitalization for E. K. G. Um whether or not they have ventricular dysfunction or coronary artery changes would then guide how often we're checking a BMP. Troponin E. K. G. And ECO. Um But we're assessing them pretty frequently until things stable at guys. And these were based on guidelines published in circulation back in the fall. Mhm. And then typically after discharge, what we're doing is following the Kawasaki and myocarditis. Outpatient follow up. You know, there's a lot of data that have created previously well established guidelines for Kawasaki disease and my myocarditis. And so we're repeating an echocardiogram around 1 to 2 weeks with an E. K. G. And then again at 4 to 6 weeks for almost all patients. Um we continue the aspirin as shown on this slide until the 4-6 week checkup. When at that point we confirmed that if coronary arteries have normalized, left ventricular systolic function has normalized, then we typically just continue the aspirin in conjunction with rheumatology, presuming that employment ori markers and platelets have normalized. Um Many of these patients have gone home on steroid tapers as well. And so we are co managing with our rheumatology colleagues. So the big topics that kind of led to the return to play discussion was what are the long term implications after covid? So I mentioned are short term follow up for M. I. S. C. Which you know the covid patients. Um It was a little bit less well established. Um and there was a lot of concerned that there was a significant number of people who were going to have myocardial involvement after having covid 19. And so you know, back last summer, last spring there were, you know the big 10 Impact 12. They postponed their seasons. And there were all of these um protocols developed for safely returning to play in the professional and collegiate atmosphere which now have kind of trickled down into the pediatric population. So post viral myocarditis, it's a well documented cause of sudden death during exercise. Um, initial studies is, uh, and this was previous to covid um, with other viruses. And so initial studies that kind of caused a lot of this panic. We're reporting anywhere from 1.5 to 56% of people with covid would have myocardial involvement. And over time this has been refined to be far less alarming. Um, you know, the initial studies reporting high percentages of disease, they did not use standardized definitions of myocardial disease and had inconsistent conclusions of what constituted cardiac involvement versus benign variation seen in asymptomatic athletes. Um, so this is a very busy slide. Just kind of want to draw your attention to a couple of things, you know, a a p guidance on the topic has um This is a document that was created by rady Children's in conjunction with the southern California ap chapter. And essentially just a few things that I want to go over from this document and then we'll go over it from more of a cardiology perspective. So um this is a pretty conservative screening recommendation that if anyone had covid 19 in the past six months then you go through this algorithm. Some places are saying three months and that's just because of what we know about myocarditis and these patients um with M. I. S. C. Or covid and myocarditis. They've largely recovered within 30 days. Um and the outliers have recovered within six months. And so if you're being more conservative history of covid within the past six months um is kind of the cut off or when you would need potentially additional screening um you know, a current history and physical is the first step. So symptoms of concern, chest pain, shortness of breath out of proportion for the U. R. S. That they experienced sync api and new onset palpitations or any abnormalities in cardiac exam are obviously things that need to be discussed with the cardiologist and potentially referred. Um The AP is defining a symptomatic and mild symptoms is less than four days of fever. Um Less than one week of myalgic chills or lethargy. Those patients, regardless of age, if they are still asymptomatic and don't have anything concerning on their physical exam would be cleared for participation without any additional work up. The patients in the moderate category. Those with greater than 40s of fever greater than one week of my algae Children left 30. Those are the patients that we kind of risk stratify based on age and um level of participation. So the A. P. And this document was following the initial A. Cc. Guidance of a cut off of 12. The A. C. C. Is currently recommending um 15 and again I think it really has to do more with the level of physical activity and whether or not they're pre or post pre ready. And so um in the patients who are 15 12 or 15 depending on your cut off and had moderate symptoms and they are participating in high intensity physical activity. So significantly highly intensive competitive athletics we're going to consider E. C. G. And or referral to cardiology prior to participation if anyone has any abnormally CG or had severe symptoms or M. I. S. C. These are the patients that are already plugged into cardiology. And so really it's these patients with the moderate symptoms and the competitive athletes um that warrant further investigation and a little bit more nuanced on how to do it. Okay so this is um the Jama cardiology published back in the fall. They're returned to play following covid and M. I. S. C. And again they this came out a little bit after the A. C. C. Document that was using 12 as a cut off. They suggest 15 which I think based on um the intensity of athletic participation makes a lot of sense in most cases. Um That age is greater than 15 would be considered more with the adult guidelines. So to go over there, pediatric algorithm um Less than 15 the asymptomatic and mildly symptomatic patients um You know, everybody should be resting and not exercising for 10 days after their positive test should have full resolution of all of their symptoms before they're returning to play. But otherwise no initial testing instigated based on this algorithm unless they have any persistent or recurrent cardiac symptoms for the moderately symptomatic patients, whether it was cardiovascular or not. So the greater than 40 is a fever greater than one week of my algebra based on the ap guidance after their self isolation, um, should be assessed by their general pediatrician after resolution of symptoms. And this is where you would consider your risk stratification with E. K. G troponin and eco proponents are not typically included in the ap documents um, and are something that's a little bit more controversial in the pediatric population, um, but can certainly be considered on an individual basis. And then for greater than age 15, I'm just gonna take you to the result algorithm to go over that. So in the adult world, um, same thing asymptomatic and mildly symptomatic, you know, after their isolation and resolution of any of their symptoms. They can go back to return to play without any additional evaluation. The severe symptoms that were hospitalized again are already plugged in. And so really it's these moderate at least symptomatic patients where there is some latitude about how to further work them up. And so um the adult um algorithm is saying that for anybody who had moderate symptoms they're performing an E. K. G. Troponin and echocardiogram automatically as screening. And again this is different than our pediatric recommendations. But the BCG troponin and echo as an initial screen if there's any abnormalities there than a cardiac MRI. Is considered cardiac MRI. Um has been widely studied since. And I'll get into a couple of studies that kind of go through the utility of cardiac MRI. And what we're looking for. Once we've confirmed the diagnosis of MSC or myocarditis and those patients are followed by cardiology. Again, what I mentioned with that kind of 3 to 6 months window before return to play is exactly what we're following. And so um no less than three months. Would we repeat an evaluation and consider cardiac clearance for a patient who had known M. I. S. C. Or myocarditis? And so typically sometimes depending on the level of involvement, we push it closer to six months before we reassess. And essentially what we're doing is repeating an echo military monitoring, exercise stress testing and potentially cardiac MRI. Um and serum markers such as proponent or BNP. And all of that has to be normal before they're allowed to resume activity because of the increased risk of arrhythmia in patients who have ongoing myocardial inflammation. So getting into the studies that kind of go over um these screening algorithms in professional athletes and collegiate athletes and the use of cardiac MRI. So I think it's really important to understand cardiac MRI. Um is a limited screening school. We have one machine in our hospital um and it uh takes a A couple of hours to obtain a study um in patients under age 12. It requires sedation typically. And so um using MRI screening is not realistic, which is mentioned in many of these studies. Um and so the question is what level of screening is where we're going to hit the appropriate cut off of detecting the maya cardio bill inflammation that's clinically significant. And so recent studies have been largely reassuring compared to the initial studies that came out regarding think curry back in development. So this this the study that came out March, Jama cardiology that was assessing professional athletes tested positive for covid, anybody who tested positive automatically got a troponin T. K. G. And um echocardiogram. So many of the um athletic organizations have been far more conservative than the originally published and suggested guidelines. And we're obtaining testing even in the asymptomatic patients. And of these patients, um 58 of that 58% of them were symptomatic. Uh None of them had severe symptoms. One was hospitalized overnight for non cardiac symptoms. 30 athletes or 3.8% were sent for additional testing. 27 of them received a cardiac MRI. And um five of these um were shown to have either myocarditis or pericarditis. So about .6 um had confirmed myocarditis repaired card itis by M. R. I. And these five athletes had moderate symptoms during their covid 19 illness. So essentially this study um was very much validating uh the recommendations from back in the fall last fall that additional screening of mildly symptomatic or asymptomatic athletes is unlikely to have a high yield uh Around nobody is on the MRI. This is a study um cardiac involvement in collegiate athletes. This has been an X accepted for publication in circulation. Um And um the final publication uh uh huh hasn't been as included athletes who had any positive test for stars Kobe to the data was collected from september to december of 2020 including 42 ledges in universities. There were almost 20,000 it wasn't uh and what they found and I'll go through there common mhm mm symptoms. So chest pain, shortness, normal triad test. The troponin T. C. G. Or echocardiogram were predictive of cardiac involvement on cardiac MRI. There was one athlete who was successfully resuscitated from a sudden cardiac arrest, but this patient or this athlete had At a normal cardiac MRI 17 days after their symptom onset. And so the ideology of their arrest is uncertain, but thought to be unlikely related to um their stars Kobe to positive test. Mhm. So what this study found was that there was cardiac involvement in .5-3% of young, otherwise healthy individuals, the collegiate athletes, and this is an important point that they make again, similar to the rates of myocarditis following influenza. And this because it was over many different universities, there were a lot of different protocols. So there were 119 who underwent a cardiac MRI because of cardio respiratory symptoms or an abnormal triad test. And in those patients, 12.6% of them were diagnosed with definite probable or possible cardiac involvement. Then there were another 298 who went through cardiac MRI as primary screening, and 3% of those were diagnosed with cardiac involvement. And so, essentially these are patients where cardiac MRI was just part of the protocol. There was just a study published last week with the athletes from the Big 10 that was showing basically cardiac MRI was part of their protocol. And I'm assuming a lot of these 198 athletes were in that study as well. And they found a very similar rate somewhere between two and 3%. If you perform a cardiac MRI as primary screening, 2 to 3% are going to have some sort of cardiac involvement on their cardiac MRI. And so, basically, what this meant was that there were three that were asymptomatic or have mild symptoms of covid with normal triad testing. That then got picked up by a screening MRI. Mhm. And that's just shown here. So, the 198 athletes that were just automatically screened with cardiac MRI versus the 2800 athletes that had initial screening with either clinical symptoms or abnormal tried testing and um showing that in these patients that were pre screened with clinical uh In key chain. And um there was a .5% much like the professional athletes study, versus 3% much like the big 10 study where everybody was getting an MRI. And the problem with this is that there MRI um diagnosis of myocarditis and the criteria that is used to define myocarditis. It's only been tested and validated in symptomatic patients. And so it's hard to know what it means when we find some of these things in asymptomatic individuals that could potentially represent normal changes in an athletic, highly athletic population. And so the other thing that I thought was really interesting about this study, um you know, in these 3000 patients there were 56 athletes who were found to have in cardiac abnormality that was completely unrelated to covid. And so it just goes to show when you look for things you're going to find them much like these MRI abnormalities. And some of these cardiac diagnoses are things that would lead to athletic restriction um such as hypertrophic cardiomyopathy, LV, non compaction, cardiomyopathy and prolonged Q. T. Syndrome. Yeah. So there are conclusions again kind of validated the previously published risk stratification and screening algorithms by um the A. C. C. And H. A. Um You know, they are arguing that athletes with asymptomatic or mild symptoms do not require additional testing. The triad testing with BCG proponent and Echo can be considered for the moderate symptoms um or people with cardiopulmonary symptoms which was the most important marker of risk and the yield of obtaining a cardiac MRI is optimized if we can find it's used to athletes with the increased pretest probability. So those who have cardiopulmonary symptoms or abnormal try a testing. So this is really where we need to consider our risks versus benefits. Um You know, we have a very small risk of inflammatory cardiac disease versus the consequences of not being able to participate in athletic activity. And I would argue that um, you know, being a competitive athlete is largely protective against covid in many ways. Um and we know that obesity is one of the most significant risk factors for severe covid. Um We've all seen the increased rates of pediatric obesity and the worst thing mental health crisis amongst our pediatric patients and participating in athletic activities. He is certainly going to help with both of those things um In addition, prolonged de conditioning, leading to change in habits affecting long term cardio balance that needs to be established for each patient. And I think the risk versus benefit profile um is really something that is an individual thing that needs to be taken into account with each family and each athlete. Yeah, So right. When we thought that things were settling down, the numbers are going down, there's more the recent media regarding the myocarditis cases after vaccination seems like there is going to be an association and another risk benefit profile that we're all going to have to assess. And so, Um, Israel was one of the first places to report their link between the cases of myocarditis and COVID-19 vaccination and young men. Um, it has also been reported in the United States, in the Department of Defense and now there are cases that are being published likely this week. Um If we look at the vaccination data here in Alameda County, we've got 33,012-15 cohort that have received their first dose. Then we're just starting to get to the second dose for that age range. Unfortunately 16 and up is now lumped in with everyone up to 34. Um but those numbers obviously are pretty high nationally as well. Yeah and so um you know essentially what um going on and this is all updated as of this morning. Um I went over everyone's recommendations again just to make sure I'm still getting updated information. The C. D. C. The California Department of Health and the ap continue to recommend vaccinating everyone who is eligible. The data from there's the vaccine adverse event reporting system. Um do show that in the 30 day window following those two of the covid vaccine, the MMr vaccines, there was a higher number of observed than expected myocarditis versus and pericarditis cases in 16 to 24 year olds. Um, but so far the rates seem low enough that everyone is still saying that the benefits of vaccination outweigh the risks. Um, if we look at the specific guidance for clinicians from the CDC, the case is that they're reporting are mostly males who are 16 and up within several days of their second dose. This is very consistent with the Israeli data that was just reported out yesterday. They've estimated a one in 3001 in 6000, um, incidents in the males of the age 16 to 24 or I believe that's the cut off. And essentially what their data showed was that if you look at rates of myocarditis and the entire population since they began vaccinating back in january the day, The racer are similar to base plan but if you just isolate Lee males aged 16-24 there is an increased incident in that cohort. And so um here in our institution we have two cases at Oakland in two cases at san Francisco that we've reported to bears um that are possibly associated with the second dose of the um M. RNA vaccine. And all four of ours are male. All for over 16. And um all of them were recently getting there are three of the four were recently getting their second dose. One was after the first dose that he had a history of covid. So what this BDC is recommending at this time is and I'll go over this a little bit more. But for initial evaluation um you know depending on your level of suspicion and how sick the patient appears or seems. You can consider an E. C. G. Troponin and inflammatory markers such as crp. And said rate. And in the setting of all of those being normal. Myocarditis and pericarditis are unlikely. Obviously anybody who has symptoms of any sort of human dynamic instability or really severe symptoms this should happen in an emergency department just to review myocarditis briefly so that everyone kind of remembers what to be looking out for. Myocarditis is an instrument inflammatory disease of the myocardial. I'm caused by pretty much everything. Um but impedes is most often infectious. And so this is where it's going to be super challenging for us to prove any sort of association between the vaccine and myocarditis Because um you know of our four patients I think three of them had something else on this list as well. Um And uh you know for example I'm just pointing out and said um you know somebody taking ibuprofen after their vaccine. Is that going to confound our ability to determine causality here causation. Um And so as we know um I edited the slide to reflect that stars Kobe to um causes myocarditis. And so does M. I. S. C. And as we went over earlier, the rates especially with M. I. S. C. Are quite high. Um Compared to the small rates that were thinking are being seen potentially in association with the vaccine. Uh huh. So the clinical presentation varies widely and that's part of what's really scary about myocarditis patients can be asymptomatic as seen in these studies that were published about collegiate athletes and professional athletes that were getting screening and found out of subclinical myocardial tous versus cardio myopathy. With really severe left ventricular dysfunction can mimic dilated cardio myopathy, or malignant arrhythmias that can um you know, first presentation can be sudden cardiac arrest thankfully the report reported cases thus far in the United States seem to be mild. Many of the details have not been published or are not available yet. Um What I can say as far as the Israel data is that those were also reported to be mild. Um They did keratitis that were thought not to be associated with the vaccine. Under further investigation asIA to concern warning signs and symptoms proportion to the cleaning with anti pirate IX in the setting of fever or worsens with fluid resuscitation. Um That is definitely concerning from myocarditis, especially if it worsens with fluid resuscitation than we're being. We're concerned about our ventricular function. Do you have an acute persistent and severe chest pain? New onset arrhythmia? So significant activity, ventricle, Hillary arrhythmias and oclock. New onset heart block can be um That's my until proven otherwise. Um Clear vaso vagal trigger or metastatic association such as upon immediately standing, anybody with acute shortness of breath or to kenya that's not otherwise um able to be explained. Gi symptoms can be prominent in myocarditis with nausea, abdominal pain and vomiting. Thought to be secondary to gut esquina and a gallop on Oscar rotation. The associated E. C. G. Abnormalities are much like the E. K. G. That I showed you earlier um Where um that patient that I should be showing one with S. T. Elevation and depression but the one that I showed you earlier, the inversion in the lateral leads so the five and the six of the T waves. Absolutely is an abnormality that needs additional investigation. Diffuse the decreased QRS voltages. Any form of car block that's new and in any tacky arrhythmia. Mhm. This is a E. K. G. From a patient that I admitted back in january. This is not covid related but a great example of myocarditis. This is a 14 year old male who came into our er with several days of severe chest pain, fever and cough and remember this is january. So everyone thought it was covid. Um But it was not. He tested covid negative um did not meet criteria for M. I. S. C. And he was found on his respiratory viral panel to be rhino and enterovirus positive. And his proponent was 25 which is very high. His BCG was mimicking an acute coronary syndrome which is which can happen in myocarditis. And so he had localized BCG abnormalities. Here you can see the S. T. Elevation in the inferior leads and there's slight elevation that's a little bit more subtle in the lateral leads. His echocardiogram had inferior wall motion abnormalities, otherwise normal left ventricular systolic function and his MRI was consistent with myocarditis. He had myocardial Adina and sub cardio late gadolinium enhancement. And so um MRI is a really helpful tool in situations like this because the pattern of gadolinium enhancement is different in myocarditis versus myocardial infarction. This is just showing um as I mentioned earlier when we were going through the studies and athletes the diagnostic criteria for myocarditis um using FmRI is very specific. It's called the lake louise criteria. Essentially what they're evaluating for is myocardial oedema. And then early gadolinium enhancement indicating high premium and capillary leak and late gadolinium enhancement indicating biocyte injury and fiber success. Um And so again this criteria has been well validated for symptomatic individuals but we're not really sure how to interpret if we have these findings and otherwise asymptomatic athletes in particular. Mhm. So my punch line, I just wanted to say, hey, um you know, I threw a lot of data that you guys and I think it's really important that locally we all remember, you know, covid and Mfc are winning, The case rates are really low right now. Um and so um you know, hopefully when we're talking about return to play, there's not gonna be 1/4 surge that we're going to have to deal with. And um you know, we're kind of headed into that 3 to 6 month window past our surge where um you know, I think we can safely clear a lot of people for resuming athletic activity. Individualizing your approach to cardiac screening is going to be crucial, especially for the fifth cohort that are uh at really high level. Um the guidance is to continue vaccinating as the effects of the covid vaccination largely outweigh the currently identified risks