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Sports Medicine

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

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Cardiology

Published Online: January 14, 2021

Brief Report

Article Information and Disclosures

Jitka Starekova, MD¹;

David A. Bluemke, MD, PhD^1,2;

William S. Bradham, MD, PhD^1,3;

Lee L. Eckhardt, MD³;

Thomas M. Grist, MD^1,2,4;

Joanna E. Kusmirek, MD¹;

Christopher S. Purtell, MD³;

Mark L. Schiebler, MD¹;

Scott B. Reeder, MD, PhD^1,2,3,4,5

Author Affiliations

¹Department of Radiology, University of Wisconsin, Madison
²Department of Medical Physics, University of Wisconsin, Madison
³Department of Medicine, University of Wisconsin, Madison
⁴Department of Biomedical Engineering, University of Wisconsin, Madison
⁵Department of Emergency Medicine, University of Wisconsin, Madison

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Key Points

Question What is the utility of cardiac magnetic resonance imaging (MRI) as a part of a comprehensive screening program to evaluate student athletes recovering from coronavirus disease 2019 (COVID-19)?

Findings In this study of 145 student athletes with COVID-19 who had mild to moderate symptoms or no symptoms during acute infection, cardiac MRI findings (at a median of 15 days after a positive test result for COVID-19) were consistent with myocarditis in only 2 patients (1.4%), based on updated Lake Louise criteria.

Meaning Based on a low prevalence of COVID-19–associated findings consistent with myocarditis in 145 competitive student athletes with mild to moderate or no COVID-19 symptoms and normal serum study results, the utility of cardiac MRI as a screening tool for myocarditis was low and concordant with normal laboratory serum assays.

Abstract

Importance 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 Participants In 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 Measures Prevalence 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 Relevance In 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.

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Article Information

Accepted for Publication: December 15, 2020.

Published Online: January 14, 2021. doi:10.1001/jamacardio.2020.7444

Corresponding Author: Scott B. Reeder, MD, PhD, University of Wisconsin–Madison, Department of Radiology, 600 Highland Ave, Madison, WI 53792 (sreeder@wisc.edu).

Author Contributions: Drs Starekova and Reeder had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Starekova, Eckhardt, Reeder.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Starekova, Purtell, Schiebler, Reeder.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Starekova, Reeder.

Obtained funding: Grist, Reeder.

Administrative, technical, or material support: Bluemke, Grist, Schiebler, Reeder.

Supervision: Grist, Kusmirek, Schiebler, Reeder.

Conflict of Interest Disclosures: Dr Reeder is a Romnes Faculty Fellow and has received an award provided by the University of Wisconsin–Madison Office of the Vice Chancellor for Research and Graduate Education with funding from the Wisconsin Alumni Research Foundation; reported that the University of Wisconsin receives research support from GE Healthcare and Bracco Diagnostics, outside the submitted work; and has ownership interests in Calimetrix, Reveal Pharmaceuticals, Cellectar Biosciences, Elucent Medical, and HeartVista and has received investigator-initiated grant support from Bayer Healthcare for research, outside the submitted work. Dr Grist has ownership interests in Elucent Medical, Shine Medical Technologies, OnLume, and Histosonics, outside the submitted work. Dr Grist also reported grants from Bracco Diagnostics Inc, research support to institution and grants from GE HealthCare Research support to institution during the conduct of the study, and personal fees from Bracco Diagnostics Inc advisory board, outside the submitted work. Dr Schiebler has ownership interests in Healthmyne Inc, Stemina Biomarker Discovery Inc, and X-Vax Inc, outside the submitted work. Dr Eckhardt is funded in part by the Gary and Marie Weiner Professorship in Cardiovascular Medicine Research. No other disclosures were reported.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.