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Cardiology

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

JAMA Cardiology

Published Online: May 27, 2021

Original Investigation

Article Information and Disclosures

Curt J. Daniels, MD¹;

Saurabh Rajpal, MBBS, MD¹;

Joel T. Greenshields, MS²;

Geoffrey L. Rosenthal, MD³;

Eugene H. Chung, MD⁴;

Michael Terrin, MD³;

Jean Jeudy, MD³;

Scott E. Mattson, DO⁵;

Ian H. Law, MD⁶;

James Borchers, MD⁷;

Richard Kovacs, MD⁸;

Jeffrey Kovan, DO⁹;

Sami F. Rifat, MD⁴;

Jennifer Albrecht, PhD³;

Ana I. Bento, PhD²;

Lonnie Albers, MD¹⁰;

David Bernhardt, MD¹¹;

Carly Day, MD¹²;

Suzanne Hecht, MD¹³;

Andrew Hipskind, MD¹⁴;

Jeffrey Mjaanes, MD¹⁵;

David Olson, MD¹³;

Yvette L. Rooks, MD¹⁶;

Emily C. Somers, PhD⁴;

Matthew S. Tong, DO¹;

Jeffrey Wisinski, DO¹⁷;

Jason Womack, MD¹⁸;

Carrie Esopenko, PhD¹⁹;

Christopher J. Kratochvil, MD²⁰;

Lawrence D. Rink, MD⁵;

for the Big Ten COVID-19 Cardiac Registry Investigators

Author Affiliations

¹Division of Cardiology, Department of Internal Medicine, Ohio State University, Columbus
²School of Public Health, Indiana University, Bloomington
³University of Maryland School of Medicine, Baltimore
⁴University of Michigan, Ann Arbor
⁵Indiana University School of Medicine, Bloomington
⁶University of Iowa Stead Family Children’s Hospital, Iowa City
⁷Ohio State University, Columbus
⁸Indiana University School of Medicine, Indianapolis
⁹Michigan State University, East Lansing
¹⁰University of Nebraska, Lincoln
¹¹University of Wisconsin School of Medicine, Madison
¹²Purdue University, West Lafayette, Indiana
¹³University of Minnesota, Minneapolis
¹⁴Indiana University, Bloomington
¹⁵Feinberg School of Medicine, Northwestern University, Chicago, Illinois
¹⁶University of Maryland at College Park, College Park
¹⁷Penn State Health Sports Medicine, State College, Pennsylvania
¹⁸Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
¹⁹Rutgers Biomedical and Health Sciences, Newark, New Jersey
²⁰University of Nebraska Medical Center, Omaha

Big Ten COVID-19 Cardiac Registry Investigatorsfor the

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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.

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.