COVID-19 Myocardial Pathology Evaluation in Athletes With Cardiac Magnetic Resonance (COMPETE CMR)
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Myocarditis is a leading cause of sudden cardiac death among athletes and may occur without antecedent symptoms. Coronavirus disease 2019 (COVID-19)–related cardiac magnetic resonance (CMR) abnormalities have been described in 78% of mostly ambulatory adults,1 creating concerns over COVID-19–related myocarditis in athletes. A report of 26 COVID-19–positive collegiate athletes revealed late gadolinium enhancement (LGE) in 46%, with 4 (15%) meeting modified Lake Louise criteria for myocarditis.2,3 However, without an athletic comparator group it is difficult to discern whether LGE represents healing myocarditis or athletic remodeling, because inferoseptal right ventricular insertion LGE is common among athletes.4 We report the findings of a larger CMR study to evaluate the prevalence and extent of cardiovascular pathology among COVID-19–positive collegiate athletes, with comparison with athletic and healthy control groups.
The data supporting the findings of this study are available from the corresponding author on request. All COVID-19–positive athletes underwent an institutionally mandated cardiovascular screening protocol, including clinical examination, electrocardiography, troponin I, echocardiography with strain, and contrasted CMR with parametric mapping on a 1.5T Siemens Avanto Fit magnet (Siemens Healthcare Sector, Erlangen, Germany). The subjects were retrospectively enrolled. Athletic controls were retrospectively selected from collegiate and tactical athletes (military personnel) referred to our center for clinical CMR before the first reported case of COVID-19 in our region. All athletes in our study participated in ≥6 hours of intense physical exercise weekly. Healthy controls (N=27) similar in age to COVID-19–positive athletes were derived from a cohort of 54 healthy subjects prospectively enrolled for noncontrasted CMR to derive normative T1 and T2 values for our laboratory. The study was approved by the institutional review board with a waiver of consent for retrospective enrollment.
Contrasted studies were performed using 0.15 mmol/kg of gadobutrol. Volumetric and parametric mapping analyses were performed using Qmass and Qmaps (MedisSuite, Leiden, The Netherlands). Punctate inferoseptal right ventricle insertion LGE was not considered a pathological exclusion criterion.4
Categorical variables were compared using the chi squared test, and continuous variables were compared using the Wilcoxon rank sum. Statistical analysis was performed using STATA, version 15 (StatCorp LLC, College Station, TX) software.
Fifty-nine COVID-19–positive athletes, 60 athletic controls, and 27 healthy controls were included in our analysis (Table). The COVID-19–positive athletes represented 9 collegiate sports; 63% were female and 15% were non-White, and the median age was 20 years. The median time from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection to CMR was 21.5 days (interquartile range, 13–37; range, 10–162). COVID-19–positive athletes experienced mild illness (N=46 [78%]) or were asymptomatic (N=13 [22%]).
| COVID-19–positive athletes (N=59)*† | Healthy controls (N=27)* | Athletic controls (N=60)† | P value* | P value† | |
|---|---|---|---|---|---|
| Age, median (IQR), y | 20 (19–21) | 30 (27–34) | 25 (22–27) | <0.001 | <0.001 |
| Height, cm | 173 (164–188) | 173 (164–183) | 175 (173–185) | 0.50 | 0.17 |
| Weight, kg | 67 (59–91) | 73 (66–86) | 85 (72–95) | 0.46 | 0.01 |
| Body surface area, kg/m2 | 1.8 (1.6−2.2) | 1.9 (1.7–2.0) | 2.1 (1.9–2.2) | 0.85 | 0.03 |
| Race: non-White, N (%) | 6 (15%)‡ | 3 (13%)§ | 3 (21%)∥ | 0.81 | 0.55 |
| Ethnicity: non-Hispanic, N (%) | 36 (95)¶ | 22 (88)# | 13 (87)** | 0.33 | 0.32 |
| Gender: Female, N (%) | 37 (63)†† | 10 (37)‡‡ | 7 (12)§§ | 0.04 | <0.001 |
| Echocardiography | |||||
| LVEF, % | 61 (57–66) | NA | 60 (58–61)∥∥ | 0.24 | |
| GLS, % | −18.6 (−20.1 to −17.4)¶¶ | NA | NA | ||
| CMR | |||||
| Volumetrics | |||||
| LVEF, median (IQR), % | 60 (56–63) | 60 (57–64) | 58 (56–60) | 0.46 | 0.03 |
| LVEDV, mL | 160 (143–213) | 164 (138–210) | 195 (167–235) | 0.61 | 0.02 |
| LVEDVi, mL/m2 | 93 (84–100) | 88 (78–99) | 95 (86–111) | 0.12 | 0.37 |
| LVESV, mL | 68 (58–84) | 64 (55–83) | 84 (66–97) | 0.32 | 0.007 |
| LVESVi, mL/m2 | 37 (34–43) | 35 (31–41) | 40 (35–47) | 0.21 | 0.08 |
| LV mass, g | 112 (88–147) | 71 (57–96) | 117 (105–143) | <0.001 | 0.26 |
| LV mass index, g/m2 | 60 (52–71) | 41 (32–48) | 59 (53–67) | <0.001 | 0.48 |
| RVEF, % | 53 (50–56) | 58 (55–60) | 53 (51–57) | <0.001 | 0.53 |
| RVEDV, mL | 184 (153–240) | 166 (136–210) | 201 (170–241) | 0.08 | 0.19 |
| RVEDVi, mL/m2 | 100 (91–115) | 89 (78–104) | 99 (87–117) | 0.004 | 0.61 |
| RVESV, mL | 86 (70–117) | 67 (58–86) | 94 (73–116) | 0.002 | 0.46 |
| RVESVi, mL/m2 | 48 (42–55) | 36 (32–45) | 45 (40–55) | <0.001 | 0.53 |
| Parametric mapping and LGE | |||||
| T1, median (IQR), ms | |||||
| Basal septum | 992 (970–1007) | 988 (972–1000) | 990 (973–1003)## | 0.44 | 0.64 |
| Basal lateral | 972 (952–995) | 958 (945–983) | 966 (954–993)## | 0.13 | 0.91 |
| Mid septum | 988 (973–1013) | 979 (963–1000) | 982 (960–997)*** | 0.15 | 0.12 |
| Mid lateral | 984 (951–996) | 965 (947–975) | 965 (948–987)*** | 0.06 | 0.07 |
| T2, ms | |||||
| Basal septum | 44.3 (42.8–46.2) | 42.8 (41.7–43.6) | 43.2 (42.4–44.2)††† | 0.001 | 0.28 |
| Basal lateral | 45.4 (44.1–46.6) | 44.2 (43.0–44.6) | 44.2 (43.2–45.3)††† | <0.001 | 0.25 |
| Mid-septum | 46.8 (44.9–48.4) | 44.7 (43.3–46.1) | 44.9 (43.9–46.4)‡‡‡ | <0.001 | 0.02 |
| Mid-lateral | 47.0 (44.9–47.9) | 44.4 (42.6–45.5) | 45.6 (44.0–46.9)‡‡‡ | <0.001 | 0.21 |
| ECV, % | |||||
| Basal septum | 24.6 (22.8–25.9)‡‡‡ | NA | 22.9 (20.8–26.3)††† | 0.54 | |
| Basal lateral | 22.5 (20.7–24.2)‡‡‡ | NA | 23.9 (20.8–25.8)††† | 0.42 | |
| Mid-septum | 25.6 (23.9–27.7)§§§ | NA | 22.7 (21.6–24.3)∥∥∥ | 0.006 | |
| Mid-lateral | 23.9 (21.6–25.6)§§§ | NA | 20.8 (19.9–24.8)∥∥∥ | 0.05 | |
| LGE (any), N (%) | 16 (27%) | 0 | 10 (24%)¶¶¶ | 0.56 | |
| Mid-inferior RV septal insertion site (without myocarditis) | 13 (22%) | 0 | 10 (24%)¶¶¶ | 0.69 | |
| Meeting modified Lake Louise criteria | 2 (3%) | 0 | 0 | ||
| Other myocardial | 1 (2%) | 0 | 0 | ||
| Pericardial | 1 (2%) | 0 | 0 | ||
Two asymptomatic COVID-19–positive athletes (3%) met criteria for myocarditis2; 1 athlete had pericarditis. These athletes had normal electrocardiograms, troponin I, and echocardiograms with strain. Both athletes with myocarditis had normal left ventricular ejection fraction by initial CMR; however, 1 athlete developed new left ventricle dysfunction (left ventricular ejection fraction, 45%) on a follow-up echocardiogram performed for worsening dyspnea.
COVID-19–positive athletes had increased volumes and mass when compared with healthy controls, consistent with athletic remodeling. Most standard CMR parameters were similar between COVID-19–positive athletes and athletic controls. Focal LGE isolated to the inferoseptal right ventricle insertion was present in 22% of COVID-19–positive athletes, compared with an identical LGE pattern in 24% of athletic controls.
COVID-19–positive athletes had elevated myocardial T2 relaxation times in all myocardial segments compared with healthy controls; however, only the midseptal T2 was significantly elevated compared with athletic controls. Similarly, midseptal extracellular volume was elevated in COVID-19–positive athletes compared with athletic controls. Mild segmental increases in T1, T2, or extracellular volume were found in 39% of COVID-19–positive athletes, 13% of athletic controls, and 8% of healthy controls compared with our laboratory-specific normative values.
The prevalence of myocarditis in collegiate athletes after COVID-19 is modest (3%) but may be missed by conventional screening without CMR. Although the long-term significance of myocarditis detectable only by CMR remains unclear, 1 athlete with myocarditis did develop left ventricle dysfunction on subsequent echocardiography. Future investigations are necessary to follow COVID-19–positive athletes for long-term complications.
Our findings confirm that focal inferoseptal right ventricle insertion LGE is common in athletes, may represent remodeling from athletic training, and should not be conflated with myocarditis. Disparities in volumetrics and LGE prevalence between the COVID-19–positive athletes and healthy controls were diminished when using athletic controls as the comparator. This highlights the importance of utilizing athletic controls when interpreting CMR findings in COVID-19–positive athletes.5
There are limitations to our study. Athletic controls were preferentially matched by athletic training, not age or sex, which could contribute to differences between groups. Not all CMR were performed at a uniform time and myocardial strain was assessed only with echocardiography.
CMR with parametric mapping detects myocardial inflammation with high sensitivity. Clinical judgment remains imperative when contextualizing abnormal CMR findings in the adjudication of a safe return to athletic competition. Ongoing investigations of the short- and long-term cardiovascular manifestations of COVID-19 are necessary to inform the optimal care of athletes recovering from infection.
Acknowledgments
The authors acknowledge our exceptional cardiac magnetic resonance technologists (Shannon Bozeman, Dana Fuhs, Matt Herscher, and Miranda Tweedy) for obtaining phenomenal images and working overtime for the screening of these athletes.
Sources of Funding
Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL007411. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Research reported in this publication was also supported by CTSA award No. UL1 TR002243 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.
Disclosures None.
Footnotes
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