Cardiac MRI (CMR) might be able to find abnormalities suggestive of myocarditis after COVID-19 recovery -- or to rule them out -- but it shouldn't be used that way in the absence of symptoms, a group of cardiologists, radiologists, and others argued. "We wish to emphasize that the prevalence, clinical significance and long-term implications of CMR surrogates of myocardial injury on morbidity and mortality are unknown," they wrote in an open letter signed by some 50 medical professionals from a range of disciplines. Until there's better evidence, "testing asymptomatic members of the general public after COVID-19 is not indicated outside of carefully planned and approved research studies with appropriate control groups," the group argued. The letter called on the 18 professional societies to which it was sent, including the American College of Cardiology (ACC), American Heart Association, American College of Radiology, and the Society for Cardiovascular Magnetic Resonance (SCMR) to put out clear guidance to stop people seeking CMR screening for that purpose. SCMR responded to the open letter on Tuesday, agreeing that routine CMR in asymptomatic patients after COVID-19 "is currently not justified... and it should not be encouraged." The statement did not specifically address athletes. The controversy flared up with a German study that turned up late gadolinium enhancement and other abnormalities on CMR suggesting myocardial injury and inflammation in a group of people who recovered from largely mild or moderate cases of COVID-19 compared with healthy controls and risk factor-matched controls. Then Ohio State University researchers last week published data on CMR scans of collegiate athletes after asymptomatic or mild SARS-CoV-2 infection: 15% had findings suggestive of myocarditis and 31% had LGE without T2 elevation, suggestive of prior myocardial injury. Neither study could prove COVID-19 caused the abnormalities or say what the long-term consequences will be. But both were used for making decisions about the safety of sports. The German group was cautious about interpretation. However, the Ohio State researchers wrote that CMR could potentially separate a high-risk group from those athletes safe for participation, "because CMR mapping techniques have a high negative predictive value to rule out myocarditis." A Bloomberg story about the Ohio State data declared it a "call to screen college athletes." An Ohio State football fan site, Eleven Warriors, which has lobbied for games to proceed on schedule, took the latest study as good news. Lead author Saurabh Rajpal, MD, told the site, "So if you do an MRI, and the heart does not show myocarditis, at OSU we are letting the athletes [recovering from COVID-19] go back to practice. We are letting them go back to usual intensity of exercise if their MRI was negative." That's a bad idea for the general public, according to the letter, which noted that people have been seeking out CMR for asymptomatic screening. "My own personal opinion is that casual athletics would be included but that elite athletes might not," first author on the letter, Venkatesh Murthy, MD, PhD, of the University of Michigan in Ann Arbor, told MedPage Today. When the Big Ten conference announced Wednesday that it would resume play, it said that all athletes who test positive for the coronavirus will have to undergo comprehensive cardiac testing, including CMR, and get clearance from a university-designated cardiologist. The earliest a player can return to competition after testing positive is 21 days. Consensus guidance from the ACC's Sports & Exercise Cardiology Council on return to play calls for normalization of ventricular function, absence of biomarker evidence of inflammation, and absence of inducible arrhythmias with risk stratification after 3 to 6 months of exercise restrictions and "based on extensive testing including echocardiography, stress testing, and rhythm monitoring." For athletes, with even asymptomatic infection, it recommended that "cardiac testing should be considered if there is concern for cardiac involvement," the guidance states. Source
