Months after recovering from COVID-19, some college athletes are showing signs of heart inflammation brought on by a rare condition called myocarditis that may be linked to SARS-CoV-2 exposure, doctors reported September 11 in JAMA Cardiology.
When they imaged the hearts of more than two dozen of Ohio State University players using cardiac magnetic resonance (CMR), they found evidence of myocarditis in 15 percent, while a further 30 percent had cellular damage or swelling that could not be linked definitively to the condition.
In their report, the doctors offer an additional risk assessment tool for universities and professional sports agencies looking to balance the risk to their athletes against a desire to resume play.
“Myocarditis is a significant cause of sudden cardiac death in competitive athletes,” the authors write in the study. “Cardiac magnetic resonance imaging has the potential to identify a high-risk cohort for adverse outcomes and may, importantly, risk-stratify athletes for safe participation.”
Several large sporting events have recently been canceled, such as the Big Ten Conference (which includes Ohio State), due in part to concern over heart conditions in players who have contracted the virus.
While myocarditis is a rare condition—affecting roughly 22 out of every 100,000 people each year—it is nevertheless a recognized cause of death among professional athletes, even in the absence of previous heart trouble. A 2015 study found that among NCAA athletes who died of a sudden cardiac event, 10 percent experienced myocarditis, and a Myocarditis Foundation report found that the condition causes 75 deaths per year in athletes between the ages of 13 and 25.
ESPN reports that COVID-19 has been linked with myocarditis at a higher frequency than other viruses have been, based on limited studies and anecdotal evidence. A recent study of 100 patients in Germany found that 60 percent suffered from myocarditis following their COVID-19 diagnoses, independent of pre-existing conditions.
To assess the presence of myocarditis in college athletes that have recovered from COVID-19, the authors selected 26 students at Ohio State University, including men and women. None of the participants, who played football, soccer, lacrosse, basketball, or track, had previous heart conditions before being tested.
All 26 participants had contracted the coronavirus between June and August and had their cases verified using a PCR test. The timing between their diagnosis and their subsequent testing for myocarditis varied between 11 days to almost two months. Twelve of the athletes reported mild symptoms while sick, while the rest were asymptomatic.
Ordinarily, athletes may have their heart health assessed using a battery of tests: a physical examination, an ultrasound, an electrocardiogram, and a blood test to measure for the heart stress protein troponin I. The current study included all these tests, but also added the CMR, which the authors say was the most successful tool at identifying cases of myocarditis.
“We were able to differentiate those who had evidence of myocardial inflammation—and therefore myocarditis—from those who did not, and the [CMR] became the tool that did that with the highest sensitivity,” Curt Daniels, a cardiologist at Ohio State Wexner Medical Center and a coauthor of the study, tells the Akron Beacon Journal.
Among the 26 athletes, four met at least two criteria consistent with a diagnosis of myocarditis, while a further eight showed inconclusive evidence of strain. Among the four, all of which were men, two had experienced symptoms while the other two were asymptomatic, the authors report.
The current study “is really a step in the right direction,” Meagan Wasfy, a sports cardiologist at Massachusetts General Hospital who was not involved in the study, tells Science News. “We need more data like this.”
But Wasfy points to several important limitations that will make it difficult to apply the study’s findings more broadly. For one, it was small, did not include controls, and did not test its participants at the same time interval following their diagnosis, all facets that the authors tell Science News they plan to rectify in subsequent follow-ups.
Because of the varying times between diagnosis with COVID-19 and the heart analysis, there were several cases where the different tests the researchers used yielded different results. For example, there were cases in which the CMR identified possible signs of myocarditis even when the players’ troponin I levels or electrocardiograms were normal. In these cases, Wasfy says, it may be that the CMR is picking up the “ghost” of past inflammation, even as other symptoms have since gone away.
Myocarditis has been found in at least five Big Ten Conference athletes and among players in other conferences, two sources with knowledge of the situation tell ESPN. In addition, at least a dozen Power 5 schools have identified athletes with a post–COVID-19 myocardial injury, including asymptomatic patients. “Initially we thought if you didn’t have significant symptoms that you are probably at less risk,” Matthew Martinez, director of sports cardiology for Atlantic Health System, tells ESPN. “We are now finding that that may not be true.”
The overall concern has “made the bar higher” for returning to fall sports, Jonathan Drezner, director of the University of Washington Medicine Center for Sports Cardiology, tells ESPN. “It could be we don’t get there.”