Evaluation for Myocarditis in Competitive Student Athletes Recovering From Coronavirus Disease 2019 With Cardiac Magnetic Resonance Imaging

Abstract

The utility of cardiac magnetic resonance imaging (MRI) as a screening tool for myocarditis in competitive student athletes returning to training after recovering from coronavirus disease 2019 (COVID-19) infection is unknown.OBJECTIVE To describe the prevalence and severity of cardiac MRI findings of myocarditis in a population of competitive student athletes recovering from COVID-19. DESIGN, SETTING, AND PARTICIPANTSIn this case series, an electronic health record search was performed at our institution (University of Wisconsin) to identify all competitive athletes (a consecutive sample) recovering from COVID-19, who underwent gadolinium-enhanced cardiac MRI between January 1, 2020, and November 29, 2020. The MRI findings were reviewed by 2 radiologists experienced in cardiac imaging, using the updated Lake Louise criteria. Serum markers of myocardial injury and inflammation (troponin-I, B-type natriuretic peptide, C-reactive protein, and erythrocyte sedimentation rate), an electrocardiogram, transthoracic echocardiography, and relevant clinical data were obtained.EXPOSURES COVID-19 infection, confirmed using reverse transcription-polymerase chain reaction testing. MAIN OUTCOMES AND MEASURESPrevalence and severity of MRI findings consistent with myocarditis among young competitive athletes recovering from COVID-19.RESULTS A total of 145 competitive student athletes (108 male and 37 female individuals; mean age, 20 years; range, 17-23 years) recovering from COVID-19 were included. Most patients had mild (71 [49.0%]) or moderate (40 [27.6%]) symptoms during the acute infection or were asymptomatic (24 [16.6%]). Symptoms were not specified or documented in 10 patients (6.9%). No patients required hospitalization. Cardiac MRIs were performed a median of 15 days (range, 11-194 days) after patients tested positive for COVID-19. Two patients had MRI findings consistent with myocarditis (1.4% [95% CI, 0.4%-4.9%]). Of these, 1 patient had marked nonischemic late gadolinium enhancement and T2-weighted signal abnormalities over multiple segments, along with an abnormal serum troponin-I level; the second patient had 1-cm nonischemic mild late gadolinium enhancement and mild T2-weighted signal abnormalities, with normal laboratory values. CONCLUSIONS AND RELEVANCEIn this case series study, based on MRI findings, there was a low prevalence of myocarditis (1.4%) among student athletes recovering from COVID-19 with no or mild to moderate symptoms. Thus, the utility of cardiac MRI as a screening tool for myocarditis in this patient population is questionable.

Epidemiology and organ specific sequelae of post-acute COVID19: A narrative review

“…Alarmingly, CMR findings consistent with myocarditis were found in 4 out of 26 competitive athletes 11-53 days after recommended quarantine, while in another study CMR findings indicative of resolving pericardial inflammation were reported in 19 out of 48 student athletes, after a median of 27 days from diagnosis [65,68]. In contrast, in a more recent case series of 145 competitive student athletes, only 2 (1.4%) presented CMR findings consistent with myocarditis, 15 (range 11 to 195) days after diagnosis, with one of them having increased troponin levels [69]. This finding suggests against routine CMR screening in recovering athletes [70].…”

Return to Play for Athletes After COVID-19 Infection

“…Total Rajpal et al 2 Vago et al 4 Małek et al 5 Starekova et al 6 Clark et al 7 Martinez et al 8 Moulson et al 9 Hendrickson et al 10 Hence, the rapid evolution of data in this area continues to support the idea that the more practical and more widely available approach of testing with ECG, echocardiography, and serum troponin likely improves specificity and decreases burden of potentially unwarranted athletic restriction. The data in the article by Daniels et al 11 elevate our ability to intelligently discuss the issues with athletes, their families, coaches, performance coaches, trainers, sports scientists, and institutions, among the many stakeholders involved in the well-being of athletes within the universe of organized sports.…”

“…Both the Kim et al report 1 and our Editorial 3 at the time called for larger data sets, so that recommendations could be refined and more informed by data.In only 6 months since then, there has been a remarkable amount of information acquired, analyzed, and published regarding post-COVID-19 prevalence of cardiac abnormalities in athletes, as summarized in the Table. 2,[4][5][6][7][8][9][10][11] In a recent study of 789 professional athletes, screening consisted of serum troponin testing, ECG, and echocardiography, regardless of symptoms. 8 Thirty of these athletes (3.8%) had abnormal test results resulting in referral for CMR imaging, with 3 diagnosed with myocarditis.…”

SARS-CoV-2 Myocarditis in a High School Athlete after COVID-19 and Its Implications for Clearance for Sports

“…The presence of cardiac abnormalities during COVID-19 convalescence in athletes is much less than in adults, as shown in the study by Putmann et al (78%) [ 12 ] and Huang et al (58%) [ 17 ]. In athletes, the utility of CMR is questionable as the prevalence of myocarditis is low (1.4%) [ 18 ]. In another study of 26 consecutive elite athletes who had asymptomatic to mild COVID-19 with no ECG abnormalities and normal troponins 1–2 months after diagnosis, 19% of them had some abnormalities in CMR but no definite acute myocarditis [ 19 ].…”