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Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 InfectionResults From the Big Ten COVID-19 Cardiac Registry

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the prevalence of myocarditis in competitive athletes after COVID-19 infection, and how would different approaches to screening affect detection?

Findings  In this cohort study of 1597 US competitive collegiate athletes undergoing comprehensive cardiovascular testing, the prevalence of clinical myocarditis based on a symptom-based screening strategy was only 0.31%. Screening with cardiovascular magnetic resonance imaging increased the prevalence of clinical and subclinical myocarditis by a factor of 7.4 to 2.3%.

Meaning  These cardiac magnetic resonance imaging findings provide important data on the prevalence of clinical and subclinical myocarditis in college athletes recovering from symptomatic and asymptomatic COVID-19 infections.

Abstract

Importance  Myocarditis is a leading cause of sudden death in competitive athletes. Myocardial inflammation is known to occur with SARS-CoV-2. Different screening approaches for detection of myocarditis have been reported. The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches.

Objective  To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play.

Design, Setting, and Participants  Big Ten COVID-19 Cardiac Registry principal investigators were surveyed for aggregate observational data from March 1, 2020, through December 15, 2020, on athletes with COVID-19. For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded. Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings. Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities. Myocarditis prevalence across universities was determined. The utility of different screening strategies was evaluated.

Exposures  SARS-CoV-2 by polymerase chain reaction testing.

Main Outcome and Measure  Myocarditis via cardiovascular diagnostic testing.

Results  Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [60.4%]). Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 2.3%; range per program, 0%-7.6%); 9 had clinical myocarditis and 28 had subclinical myocarditis. If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 0.31%). Cardiac magnetic resonance imaging for all athletes yielded a 7.4-fold increase in detection of myocarditis (clinical and subclinical). Follow-up CMR imaging performed in 27 (73.0%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (40.7%).

Conclusions and Relevance  In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (2.3%) were diagnosed with clinical and subclinical myocarditis. Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis. Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing. 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. The role of CMR in routine screening for athletes safe return to play should be explored further.

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Article Information

Corresponding Author: Curt J. Daniels, MD, Division of Cardiovascular Medicine and Pediatric Cardiology, Department of Internal Medicine and Pediatrics (curt.daniels@osumc.edu), and Saurabh Rajpal, MBBS, MD, Division of Cardiology, Department of Internal Medicine (saurabh.rajpal@osumc.edu), Ohio State University, 473 W 12th Ave, Columbus, OH 43210.

Accepted for Publication: April 21, 2021.

Published Online: May 27, 2021. doi:10.1001/jamacardio.2021.2065

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Daniels CJ et al. JAMA Cardiology.

Author Contributions: Dr Daniels had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Daniels, Rajpal, Rosenthal, Terrin, Jeudy, Law, Borchers, Kovacs, Kovan, Rifat, Bento, Day, Olson, Rooks, Somers, Tong, Wisinski, Womack, Kratochvil, Rink.

Acquisition, analysis, or interpretation of data: Daniels, Rajpal, Greenshields, Rosenthal, Chung, Terrin, Jeudy, Mattson, Law, Kovacs, Rifat, Albrecht, Bento, Albers, Bernhardt, Hecht, Hipskind, Mjaanes, Olson, Rooks, Somers, Tong, Wisinski, Womack, Esopenko, Kratochvil, Rink.

Drafting of the manuscript: Daniels, Rajpal, Greenshields, Jeudy, Kovacs, Rifat, Bento, Hecht, Mjaanes, Wisinski, Kratochvil, Rink.

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

Statistical analysis: Daniels, Greenshields, Rosenthal, Terrin, Albrecht, Bento, Somers.

Obtained funding: Rajpal.

Administrative, technical, or material support: Daniels, Rajpal, Rosenthal, Jeudy, Borchers, Kovacs, Kovan, Rifat, Hecht, Hipskind, Mjaanes, Olson, Rooks, Tong, Womack, Esopenko, Kratochvil.

Supervision: Daniels, Rajpal, Chung, Terrin, Kovacs, Rifat, Bento, Olson, Tong, Rink.

Conflict of Interest Disclosures: Dr Daniels reported a donation from a family fund to support the research team and regulatory work at Ohio State University. Dr Rajpal reported grants from the Jay and Jeanie Schottenstein Foundation during the conduct of the study. Dr Albers reported that their institution, the University of Nebraska, applied for $5000 from the Big Ten Conference Cardiac Registry to cover expenses incurred in the collection and submission of data; if received by the University of Nebraska, Dr Albers will not receive any of these funds. Dr Day reported support for regulatory costs from Indiana University to their institution. Dr Somers reported grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: The Jay and Jeanie Schottenstein Family Foundation provided funding to support the collection and management and analysis of data for the Big Ten COVID-19 Cardiac Registry and the Ohio State University. The Rink Family Foundation provided funding to support the collection and management and analysis of data for the Big Ten COVID-19 Cardiac Registry. The PJ Schafer Cardiovascular Research Fund provided funding to support the collection and management and analysis of data at the University of Maryland.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: Nonauthor contributors to the Big Ten COVID-19 Cardiac Registry are listed in Supplement 3.

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