COVID-19 Myocarditis Detection in College Athletes Significantly Higher with Cardiac MRI

Including this scan improves detection of clinical and subclinical myocarditis by more than seven-fold, making it a vital part of return-to-play strategies.

Pinpointing clinical and sub-clinical myocarditis associated with COVID-19 in college athletes is greatly improved by cardiac MRI (CMR). Compared to screening patients by symptoms alone, the scan improves detection by more than seven-fold.

These findings, which add to the existing body of knowledge around the use of cardiac MRI with this group, further highlight the critical role in can play, said a team of investigators from Ohio State University (OSU). They published their findings in the May 27 JAMA Cardiology.

“These unique CMR imaging data provide a more complete understanding of the prevalence of clinical and subclinical myocarditis in college athletes after COVID-19 infection,” said the team led by Curtis J. Daniels, M.D., clinical internal medicine and pediatrics professor and director of the OSU Adolescent and Adult Congenital Heart Disease Program and Pulmonary Hypertension Program.

Concerns over how COVID-19 can affect college athletes first began to bubble up last fall when research from OSU and Penn Medicine revealed that myocarditis can occur in up to 15 percent of these individuals who recover from the virus. Later research from Vanderbilt University Medical Center indicated that the condition only impacted roughly 3 percent of athletes, however.

Related Content: Cardiac MRI Reveals Myocarditis in Competitive Athletes Recovered from COVID-19

Still, Daniels said, the possibility of myocarditis points to the need for CMR with these patients.

“The role of CMR in routine screening for athletes’ safe return to play should be explored further,” he said.

For this study his team compared the screening strategies used to determine whether athletes who had a RT-PCR-confirmed case of COVID-19 were fit to return to play. They examined cardiovascular testing data from the Big Ten COVID-19 Cardiac Registry on 1,597 athletes from 13 universities who tested positive for the virus between March 2020 and December 2020.

Of the group 37 individuals (2.3 percent) were diagnosed with COVID-19-related myocarditis. An additional nine had clinical myocarditis, and 28 were identified to have sub-clinical myocarditis.

According to their analysis, if the patients had been evaluated based on their symptoms alone, only five – 0.31 percent -- would have been properly diagnosed. In contrast, CMR for all athletes produced a 7.4-fold increase in myocarditis detection both for clinical (0.31 percent) and subclinical (2.3 percent) disease.

Ultimately, Daniels’ team said, making CMR part of the return-to-play protocol can help reassure providers and school officials that an athlete is healthy enough to resume activities. A normal imaging result eliminates the possibility of myocardial injury, they said.

“CMR imaging is highly sensitivity for identifying myocardial inflammation and in our study was able to exclude significant disease and allow safe return to play for 97.7 percent of athletes after cardiac screening,” they said. “While there may be a concern that CMR imaging is too sensitive and, therefore, unduly restrict[s] athletes from sport, such a scenario would only account for a very small proportion of the population based on our study.”

In an accompanying editorial, James E. Udelson, M.D., chief of cardiology and director of the Nuclear Cardiology Laboratory at Tufts Medical Center, applauded OSU and all sports medicine researchers for the growing body of knowledge around how the virus has affected this elite group of athletes. There is still much to learn, he said, but these findings go a long way to protecting the health of these individuals.

“The totality of data provides us with substantially more information to inform our thinking about screening and return to play than even just six months ago,” he said. “We can be reasonably certain that the prevalence of signs on CMR imaging of myocarditis…is in the range of 1 percent to 3 percent in athletes following positive COVID-19 test results.”

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