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Heart inflammation in athletes after mild, asymptomatic COVID-19 — small study

Four of 26 competitive athletes (15%) who had recovered from mild or asymptomatic COVID-19 had evidence suggestive of myocarditis, or inflammation of the heart muscle, on cardiac magnetic resonance (CMR) imaging, according to a research letter.

Researchers from The Ohio State University-Columbus performed CMR, electrocardiography, and echocardiography and measured serum troponin I levels in all competitive athletes referred to the sports medicine clinic 11 to 53 days after testing positive for coronavirus to detect myocarditis, which would flag athletes before they returned to play that they might be at high risk for sudden cardiac death.

Twelve athletes (26.9%) reported having only mild symptoms during their COVID-19 infections, including sore throat, shortness of breath, muscle pain, and fever. The remainder were asymptomatic.

While no diagnostic ST/T wave changes were evident, and ventricular volumes and function and serum troponin I levels were normal in all athletes, four male athletes showed signs of myocardial oedema (swelling) and injury on CMR. Two of them had signs of pericardial effusion, or an accumulation of excess fluid between the heart and its surrounding sac.

Eight athletes had gadolinium enhancement on CMR without T2 sequence elevation, suggesting myocarditis. Athletes with signs of myocarditis had prolonged T2 sequences compared with those without signs (59 vs 51 milliseconds), suggesting dysfunction.
Two of the four affected athletes had had only mild shortness of breath, and the remaining two reported no symptoms.

The authors noted that an earlier study also demonstrated cardiac findings in a significant number of recovered COVID-19 patients. "While long-term follow-up and large studies including control populations are required to understand CMR changes in competitive athletes, CMR may provide an excellent risk-stratification assessment for myocarditis in athletes who have recovered from COVID-19 to guide safe competitive sports participation," they wrote.

Abstract
Introduction: Myocarditis is a significant cause of sudden cardiac death in competitive athletes and can occur with normal ventricular function.1 Recent studies have raised concerns of myocardial inflammation after recovery from coronavirus disease 2019 (COVID-19), even in asymptomatic or mildly symptomatic patients.2 Our objective was to investigate the use of cardiac magnetic resonance (CMR) imaging in competitive athletes recovered from COVID-19 to detect myocardial inflammation that would identify high-risk athletes for return to competitive play.
Methods: We performed a comprehensive CMR examination including cine, T1 and T2 mapping, extracellular volume fraction, and late gadolinium enhancement (LGE), on a 1.5-T scanner (Magnetom Sola; Siemens Healthineers) using standardized protocols,3 in all competitive athletes referred to the sports medicine clinic after testing positive for COVID-19 (reverse transcriptase–polymerase chain reaction) between June and August 2020. The Ohio State University institutional review board approved the study, and informed consent in writing was obtained from participating athletes. Cardiac magnetic resonance imaging was performed after recommended quarantine (11-53 days). Electrocardiogram, serum troponin I, and transthoracic echocardiogram were performed on day of CMR imaging.
Results: We performed CMR imaging in 26 competitive college athletes (mean [SD] age, 19.5 [1.5] years; 15 male [57.7%]) from the following sports: football, soccer, lacrosse, basketball, and track. No athletes required hospitalization or received COVID-19–specific antiviral therapy. Twelve athletes (26.9%; including 7 female individuals) reported mild symptoms during the short-term infection (sore throat, shortness of breath, myalgias, fever), while others were asymptomatic. There were no diagnostic ST/T wave changes on electrocardiogram, and ventricular volumes and function were within the normal range in all athletes by transthoracic echocardiogram and CMR imaging. No athlete had elevated serum levels of troponin I. Four athletes (15%; all male individuals) had CMR findings consistent with myocarditis based on the presence of 2 main features of the updated Lake Louise Criteria: myocardial edema by elevated T2 signal and myocardial injury by presence of nonischemic LGE (Figure).4 Pericardial effusion was present in 2 athletes with CMR evidence of myocarditis. Two of these 4 athletes with evidence of myocardial inflammation had mild symptoms (shortness of breath), while the other 2 were asymptomatic. Twelve athletes (46%) had LGE (mean of 2 American Heart Association segments), of whom 8 (30.8%) had LGE without concomitant T2 elevation (Table). Mean (SD) T2 in those with suspected myocarditis was 59 (3) milliseconds compared with 51 (2) milliseconds in those without CMR evidence of myocarditis.
Discussion: Of 26 competitive athletes, 4 (15%) had CMR findings suggestive of myocarditis and 8 additional athletes (30.8%) exhibited LGE without T2 elevation suggestive of prior myocardial injury. COVID-19–related myocardial injury in competitive athletes and sports participation remains unclear. Cardiac magnetic resonance imaging has the potential to identify a high-risk cohort for adverse outcomes and may, importantly, risk stratify athletes for safe participation because CMR mapping techniques have a high negative predictive value to rule out myocarditis.4 A recent study by Puntmann et al2 demonstrated cardiac involvement in a significant number of patients who had recovered from COVID-19. A recent expert consensus article recommended 2-week convalescence followed by no diagnostic cardiac testing if asymptomatic and an electrocardiogram and transthoracic echocardiogram in mildly symptomatic athletes with COVID-19 to return to play for competitive sports.5 However, emerging knowledge and CMR observations question this recommendation. Cardiac magnetic resonance imaging evidence of myocardial inflammation has been associated with poor outcomes, including myocardial dysfunction and mortality.6 Study limitations include lack of baseline CMR imaging and variable timing of CMR imaging from a positive COVID-19 test result. Athletic cardiac adaptation could be responsible for these abnormalities; however, in this cohort, mean (SD) T2 in those with suspected myocarditis was 59 (3) milliseconds vs 51 (2) milliseconds in those without, favoring pathology. Additionally, the rate of LGE (42%) is higher than in previously described normative populations. To conclude, while long-term follow-up and large studies including control populations are required to understand CMR changes in competitive athletes, CMR may provide an excellent risk-stratification assessment for myocarditis in athletes who have recovered from COVID-19 to guide safe competitive sports participation.

Authors
Saurabh Rajpal; Matthew S Tong; James Borchers; Karolina M Zareba; Timothy P Obarski; Orlando P Simonetti; Curt J Daniels

 

[link url="https://www.cidrap.umn.edu/news-perspective/2020/09/covid-19-scan-sep-11-2020?utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_medium=email&_hsmi=95185376&_hsenc=p2ANqtz-9CXKznZBEWYa_fzXq5D5e73ESiiqx-eNfyde6ZdE1PebNVL1eEhr7uEofionrTfBfa7DeC45R8c7kRufRxRTwdfbY9yw&utm_content=95185376&utm_source=hs_email"]CIDRAP material[/link]

 

[link url="https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645"]JAMA Cardiology research letter[/link]

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