Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection
Authors: Curt J. Daniels, Saurabh Rajpal, Joel T. Greenshields, Geoffrey L. Rosenthal, Eugene H. Chung, Michael Terrin, Jean Jeudy, Scott E. Mattson, Ian H. Law, James Borchers, Richard Kovacs, Jeffrey Kovan, Sami F. Rifat, Jennifer Albrecht, Ana I. Bento, Lonnie Albers, David Bernhardt, Carly Day, Suzanne Hecht, Andrew Hipskind, Jeffrey Mjaanes, David Olson, Yvette L. Rooks, Emily C. Somers, Matthew S. Tong, Jeffrey Wisinski, Jason Womack, Carrie Esopenko, Christopher J. Kratochvil, Lawrence D. Rink, Orlando Simonetti, Karolina Zareba, Salman Bhatti, Daniel Addison, Timothy Obarski, Emile Daoud, Matthew Granger, Suzanne Smart, Jessica Mayercin-Johnson, Preethi Subramanian, Jeffery Glitt, Deborah Mitchell, Rose Chumita, Amy Mumford, Anne Garcia, Lori Garris, Hongjie Liu, Bradley Hatfield, Yuji Zhang, Douglas Boersma, Zachary Schlader, Shawn Goodwin, Nicholas Port, Taylor Zuidema, Jennifer Maldonado, Lee Eckhardt, Scott Reeder, Mathue Baker, Wayne Sebastianelli, Rebecca Wadlinger, Roberta Millard, Philip Bosha, Haley Sunday, Danae Steele, Anisa Chaudhry, Soraya Smith, Micheal Pfeiffer, John Kellerman, Gregory Billy, Jason Krystofiak, Micah Eimer
Journal: JAMA Cardiology (2021)

<h3>Importance</h3> 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. <h3>Objective</h3> To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> SARS-CoV-2 by polymerase chain reaction testing. <h3>Main Outcome and Measure</h3> Myocarditis via cardiovascular diagnostic testing. <h3>Results</h3> 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%). <h3>Conclusions and Relevance</h3> 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.