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A new cardiac magnetic resonance imaging (CMR) study to investigate the effects of a novel coronavirus infection on the heart showed signs of myocarditis in 4 of 26 competitive athletes who recovered from asymptomatic or mild cases of COVID-19.
While these and other similar results are concerned, commentators say the results are preliminary and do not indicate that comprehensive CMR screening is appropriate.
Two of the 4 patients with signs of myocarditis in this series had no symptoms of COVID-19 but tested positive on routine tests. Another 1
That finding, said Saurabh Rajpal, MBBS, MD, lead author of the study, “could suggest a previous myocardial injury or athletic myocardial adjustment.”
In the September 11th in JAMA cardiologyRajpal and colleagues at Ohio State University in Columbus described the results of extensive CMR exams on competitive athletes referred to the sports medicine clinic after receiving a positive COVID-19 test for reverse transcriptase polymerase chain reaction (RT -PCR).
The university had made the decision in the spring to use CMR imaging as a screening tool for return to play, Rajpal said. While CMR is used for research purposes, the recent Consensus Expert Opinion from the American College of Cardiology on Resuming Exercise and Exercise After COVID-19 Infection does not require CMR imaging to resume competitive activity.
None of the athletes had to be hospitalized for their illness, and only 26.9% reported mild symptoms during the short-term infection, including a sore throat, shortness of breath, myalgia, and fever.
On the day of CMR imaging, electrocardiograms, serum troponin I, and transthoracic echocardiograms were performed. There were no diagnostic ST / T wave changes, ventricular function and volume were normal, and no athletes showed elevated serum troponin levels.
The updated Lake Louise criteria were used to assess CMR findings related to myocarditis.
“I don’t think this is a COVID-specific problem,” Rajpal said in an interview. “We’ve seen myocarditis after other viral infections; it’s easy [that] COVID-19 is the most widely studied, and inflammation of the heart can be risky with strenuous activity. “He added that more long-term and larger studies with control populations are needed.
His group continues to track these athletes and has suggested that CMR “may provide an excellent risk stratification assessment for myocarditis in athletes who have recovered from COVID-19 to ensure safe participation in competitive sports”.
Meaning still unknown
Matthew Martinez, MD, director of exercise cardiology at Atlantic Health-Morristown Medical Center and the Gagnon Cardiovascular Institute in Morristown, New Jersey, cautioned if he did too much with the results of this small study.
“We know that viruses cause myocardial damage and myocarditis. What we don’t know is how important these results are,” Martinez said in an interview. “And in terms of risk, would we find the same phenomenon if we did this, for example, with flu patients or in other age groups?”
“I haven’t seen all of the pictures, but I want to know if the findings are very subtle. Are these findings obvious? Is this part of an active person with symptoms? I need to know a little more data in front of me I can tell if this affects the increased risk of sudden cardiac death, which we often associate with myocarditis, and I’m not sure how that should affect decision-making about returning to the game, “added Martinez, who was not part of the Ohio state Research of the team.
Martinez, who is the American College of Cardiology’s Chair of Exercise and Exercise but was not the author of its most recent Return to Sports Guidelines, said he does not routinely use CMR to evaluate athletes after infection as recommended by the ACC.
“My approach is to evaluate anyone with a history of COVID infection and first determine whether or not it is a major infection with significant symptoms. Then if they are participating at a high level or are a professional athlete, I would suggest one EKG, echo and troponin. This has been our recommendation for the past few months and is still a good way to evaluate this group. “
“If any abnormality or symptoms persist, I would request an MRI at this point,” Martinez said.
“We just don’t have a lot of data on athletes with no symptoms that could be used to interpret these CMR results, and the study provided no controls. We don’t even know if these results are new or old results, the one right now present now identified, “he added.
New, updated recommendations from the ACC are coming soon, Martinez said. “I don’t expect them to include CMR as the first line.”
Cardiologists Concerned About Misinformation
This is at least the fourth study to show myocardial damage after COVID-19 infection, and there is concern among the medical community that the media has overstated the risks of heart damage, especially in athletes, while overstating the benefits of CMR.
In particular, Puntmann et al. In July, about a 100-patient study that showed evidence of myocardial inflammation from CMR in 78% of patients who had recently recovered from a COVID-19 attack.
“This paper is completely problematic,” said Dr. John Mandrola of Baptist Medical Associates, Louisville, Kentucky, in an interview. “It has the same overall weaknesses, it is observational and retrospective, but there have been numerical problems too. To me, this paper is an interesting observation, but absolutely unconvincing and preliminary,” said Mandrola.
However, these limitations did not prevent the study from attracting significant media attention. The altmetric score – an attention score that tracks all mentions of an article in the media and on social media – for the newspaper by Puntmann et al. Approaching 13,000, including coverage from 276 news outlets and more than 19,000 tweets, making it in the 99th percentile of all research Altmetric has tracked to date.
To counteract this, a few days before the Rajpal study was published, an “open letter” was put online, in which the professional societies were asked to “offer clear guidelines on CMR screening for COVID-19-related cardiac abnormalities in asymptomatic members of the public discourage”. The letter was signed by 51 clinicians, researchers and imaging specialists from around the world.
Mandrola, one of the signatories, had this to say: “This issue really scares people and when it comes up in the media I think that the leaders of these societies need to come out and say something really clear on the big news outlets The People know that it is just too premature to do CMRs on any athlete who has contracted this virus, “he said.
“I understand that the current guidelines may make it clear that CMR is not a first-line test for this indication, but when the media coverage is so extensive and exaggerated, I wonder how the guidelines will affect combating this The community will be scared, “said Mandrola, who is also the chief cardiology advisor for theheart.org | Medscape cardiology.
When asked to comment on the letter, Rajpal agreed with those who signed it – that asymptomatic people from the general population do not need routine cardiac MRIs.
“However, competitive athletes are a different story,” he said. “Testing depends on the risk assessment in a given population, and according to our protocol, competitive athletes will receive an improved cardiac examination including CMR for a responsible and safe start to competitive sports. In the present scenario, we get more data, including control data, with our current protocol Continue. “
Rajpal, Martinez and Mandrola have not disclosed any relevant financial relationships.
JAMA cardiology. Published online on September 11, 2020. Research letter
This article also appears on MDedge.com, part of the Medscape Professional Network.
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