Observational Study Again Suggests Lasting COVID-19 Impact on Heart

Debra L. Beck

September 18, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

A new study using cardiac magnetic resonance (CMR) imaging to examine the effects of novel coronavirus infection on the heart showed signs suggestive of myocarditis in 4 out of 26 competitive athletes who recovered from asymptomatic or mild cases of COVID-19.

While these and other similar findings are concerning, commentators are saying the results are preliminary and do not indicate that widespread CMR screening is appropriate.  

Two of the 4 patients showing signs of myocarditis in this series had no symptoms of COVID-19 but tested positive on routine testing. An additional 12 student athletes (46%) showed late gadolinium enhancement (LGE), of whom 8 (30.8%) had LGE without T2 elevation, suggestive of prior myocardial injury.


This finding, said Saurabh Rajpal, MBBS, MD, the study's lead author, "could suggest prior myocardial injury or it could suggest athletic myocardial adaptation."

In the Research Letter published September 11 in JAMA Cardiology, Rajpal and colleagues at Ohio State University in Columbus described the findings of comprehensive CMR examinations in competitive athletes referred to the sport medicine clinic after testing positive for COVID-19 on reverse transcriptase-polymerase chain reaction (RT-PCR) between June and August.

Dr Saurabh Rajpal

The university had made the decision in the spring to use CMR imaging as a screening tool for return to play, said Rajpal. While CMR is being used for research purposes, the American College of Cardiology's recent "consensus expert opinion" statement on resumption of sport and exercise after COVID-19 infection does not require CMR imaging to resume competitive activity.

None of the athletes required hospitalization for their illness and only 26.9% reported mild symptoms during the short-term infection, including sore throat, shortness of breath, myalgias, and fever.

Electrocardiogram, serum troponin I, and transthoracic echocardiograms were performed on the day of CMR imaging. There were no diagnostic ST/T wave changes, ventricular function and volumes were normal, and no athletes showed elevated serum troponin levels.

The updated Lake Louise Criteria were used to assess CMR findings consistent with myocarditis.

"I don't think this is a COVID-specific issue," Rajpal said in an interview. "We have seen myocarditis after other viral infections; it's just [that] COVID-19 is the most studied thus far, and with strenuous activity, inflammation in the heart can be risky." He added that more long-term and larger studies with control populations are needed.

His group is continuing to follow 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 guide safe competitive sports participation."

Significance Still Unknown

Matthew Martinez, MD, the director of sports cardiology at Atlantic Health-Morristown Medical Center and the Gagnon Cardiovascular Institute, Morristown, New Jersey, urged caution in making too much of the findings of this small study.

"We know that viruses cause myocardial damage and myocarditis. What we don't know is how important these findings are," said Martinez in an interview. "And in terms of risk, would we find the same phenomenon if we did this, say, in flu patients or in other age groups?"

Dr Matthew Martinez

"I haven't seen all the images, but what I'd want to know is are these very subtle findings? Are these overt findings? Is this part of an active individual with symptoms? I need to know a little more data before I can tell if this influences the increased risk of sudden cardiac death that we often associate with myocarditis and I'm not sure how this should influence making decisions with regards to return to play," added Martinez, who was not a part of the Ohio State team's research.

Martinez, who is the American College of Cardiology's Chair of Sports and Exercise section but was not an author of their recent guidance on return to sport, said that he is not routinely using CMR to assess athletes post-infection, as per the ACC's recommendations.

"My approach is to evaluate anybody with a history of COVID infection and, first, determine whether it was an important infection with significant symptoms or not. And then, if they're participating at a high level or are professional athletes, I would suggest an ECG, echo, and troponin. That's our recommendation for the last several months and is still an appropriate way to evaluate that group."

"In the presence of an abnormality or ongoing symptoms, I would ask for an MRI at that point," said Martinez.

"We just don't have much data on athletes with no symptoms to use to interpret these CMR findings and the study didn't offer any controls. We don't even know if these findings are new findings or old findings that have just been identified now," he added.

New, updated recommendations from the ACC are coming soon, said Martinez. "I do not expect them to include CMR as first line."

Cardiologists Concerned about Misinformation

This is at least the fourth study showing myocardial damage post-COVID-19 infection and there is concern in the medical community that the media has overstated the risks of heart damage, especially in athletes, and at the same time overstated the benefits of CMR.

In particular, Puntmann et al reported in July a 100-patient study that showed evidence of myocardial inflammation by CMR in 78% of patients recently recovered from a bout of COVID-19.  

"That paper is completely problematic," John Mandrola, MD, of Baptist Medical Associates, Louisville, Kentucky, said in an interview. "It has the same overarching weaknesses, that it's observational and retrospective, but there were also numerical issues. So to me that paper is an interesting observation, but utterly unconvincing and preliminary," said Mandrola.

Those limitations didn't stop the study from garnering significant media attention, however. The Altmetric score — an attention score that tracks all mentions of an article in the media and on social media — for the Puntmann et al paper is approaching 13,000, including coverage from 276 news outlets and more than 19,000 tweets, putting it in the 99th percentile of all research outputs tracked by Altmetric to date.

To counter this, an "open letter" was posted online just days before the Rajpal study was published, urging professional societies to "offer clear guidance discouraging CMR screening for COVID-19 related heart abnormalities in asymptomatic members of the general public." 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 topic really scares people, and when it gets in the media like this, I think the leaders of these societies need to come out and say something really clear on major news networks letting people know that it's just way too premature to start doing CMRs on every athlete that's gotten this virus," he said.

"I understand that the current guidelines may be clear that CMR is not a first-line test for this indication, but when the media coverage is so extensive and so overblown, I wonder how much impact the guidelines will have in countering this fear that's in the community," said Mandrola, who is also chief cardiology consultant for theheart.org | Medscape Cardiology.

Asked to comment on the letter, Rajpal said he agrees with those who signed it — that asymptomatic people from the general population do not need routine cardiac MRI.

"However, competitive athletes are a different story," he said. "Testing depends on risk assessment in specific population and competitive athletes, as per our protocol, will get enhanced cardiac workup including CMR for responsible and safe start of competitive sports…In the present scenario, while we get more data, including control data, we will continue with our current protocol."

Rajpal, Martinez, and Mandrola have disclosed no relevant financial relationships.

JAMA Cardiology. Published online September 11, 2020. Research Letter

This article also appears on MDedge.com, part of the Medscape Professional Network.

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