COVID-19 is Rampant … In the Sports Cardiology Medical Literature
This is also published in:
COVID-19 infection is rampant not only in the general US population, but also in the Sports Cardiology medical literature. A PubMed search on January 20, 2021 using the search terms “COVID-19”, “athletes” and “cardiac” yielded 47 hits. That’s a lot of cardiology publications in less than a year for a primarily viral, respiratory disease. So what’s going on?
Of 416 patients hospitalized in the initial outbreak in Yuhan, China, 84 (19.7%) had cardiac troponin I (cTnI) values above the 95th percentile suggesting myocardial involvement. (1) A subsequent cardiac magnetic resonance imaging (cMRI) study reported evidence of “cardiac involvement” and “ongoing myocardial inflammation” in 78 and 60% of 100 German patients, respectively, who had recovered from COVID-19 infection and were imaged 64–92 days after their diagnosis. Only 33% of these patients were ill enough to have been hospitalized.(2) A cMRI study of 26 Ohio State athletes found cMRI finding “suggestive of myocarditis” in 4 (15%) of the athletes and late gadolinium enhancement “suggestive of prior myocardial injury” in another 8 (30.8%). (3) Such reports caused great concern among sports cardiologists because myocarditis is the third leading cause of sudden cardiac death (SCD) among high school and college athletes (4), and vigorous exercise transiently increases the SCD risk of any cardiac abnormality.
But where are the bodies? With all the COVID-19 and all the athletes there should be a ton of athletes with COVID-19 myocarditis and a lot of unfortunate athletes who succumbed to the myocarditis. But thankfully, I am unaware of a surge in sports related deaths during the pandemic. That could mean that the pandemic has limited sports participation thereby reducing the death rate, that the COVID myocarditis is rare, or that myocarditis in not as risky as thought.
Starekova and colleagues retrospectively reviewed cMRIs on 145 athletes after COVID-19 infection and found that only 2 (1.4%) had finding consistent with myocarditis (5) supporting the idea that myocarditis is relatively rare. The authors recommend against cMRI screening of athletes because the yield is low. This finding of 1% is only slightly reassuring, however, because given the prevalence of both COVID-19 and athletic participation, there should still be more evidence of a problem, if COVID-19 myocarditis is a problem for athletes.
At the start of this pandemic, and before I knew of COVID-19 myocardial involvement, I serendipitously wrote an editorial lamenting that we knew little about diagnosing and treating myocarditis in athletes.(6) My opinion stands: we know little about myocarditis in athletes, COVID-19 or otherwise.
So what should clinicians do? The American College of Cardiology’s Sports Cardiology Section, of which I am a part, essentially recommends cardiac evaluations only for those athletes who required hospitalization or have new or persistent symptoms.(7) That’s because this group’s collective experience was that the yield of testing was low and caused more problems than it solved. My opinion is that COVID-19 myocarditis exists, but we don’t know its prevalence and I suspect that it rarely produces clinical consequences in otherwise healthy young athletes. Nevertheless, as I said, we really don’t know, so make sure you child’s coach knows CPR and how to use the defibrillator, just in case. But they should know that anyway.
1. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, Gong W, Liu X, Liang J, Zhao Q, Huang H, Yang B, Huang C. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. .JAMA Cardiol. 2020 Jul 1;5(7):802–810.
2. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, Shchendrygina A, Escher F, Vasa-Nicotera M, Zeiher AM, Vehreschild M, Nagel E.Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020 Nov 1;5(11):1265–1273.
3. Rajpal S, Tong MS, Borchers J, Zareba KM, Obarski TP, Simonetti OP, Daniels CJ. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. 2021 Jan 1;6(1):116–118.
4. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007 Mar 27;115(12):1643–455.
5. Jitka Starekova 1, David A Bluemke 1 2, William S Bradham 1 3, Lee L Eckhardt 3, Thomas M Grist 1 2 4, Joanna E Kusmirek 1, Christopher S Purtell 3, Mark L Schiebler 1, Scott B Reeder. Evaluation for Myocarditis in Competitive Student Athletes Recovering From Coronavirus Disease 2019 With Cardiac Magnetic Resonance Imaging. JAMA Cardiol. 2021 Jan 14. Online ahead of print.
6. Thompson PD, Dec GW. We need better data on how to manage myocarditis in athletes. Eur J Prev Cardiol. 2020 Mar 30. Online ahead of print.PMID: 32228058
7. Kim JH, Levine BD, Phelan D, Emery MS, Martinez MW, Chung EH, Thompson PD, Baggish AL. Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play. JAMA Cardiol. 2020 Oct 26. Online ahead of print.PMID: 33104154
