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Key points about the latest athlete cardiac MRI paper. https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645
CMR imaging used in 26 college athletes. 12 athletes reported mild respiratory symptoms, while the rest were asymptomatic. None had typical symptoms associated with myocarditis (chest pain), and none had elevated cardiac biomarkers normally suggestive of cardiac injury.
There were no ECG changes, and all had normal chamber volumes and function by echo AND cardiac MRI imaging. (Though the attached table lists one EF at 33% (typo?)
Of 26 athletes studied, 4 had CMR findings of myocarditis, an additional 8 had LGE suggestive of prior injury. This seems alarming, and the authors do nothing in their brief discussion to provide the appropriate context.
The current recommendation for return to athletic activities suggests no testing for asymptomatic athletes, and consideration for ECG/echo/ETT in symptomatic athletes -- but the authors suggest based on recent data, CMRI may need to be added to this mix of tests
Specifically this was eye catching: "Cardiac magnetic resonance imaging evidence of myocardial inflammation has been associated with poor outcomes, including myocardial dysfunction and mortality" I recognize the reference from writing a prior medscape piece
The referenced study was an examination of 670 patients who had CLINICALLY SUSPECTED myocarditis who then got a CMRI -- and this wasn't symptomatic toe pain -- serious stuff! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506846/ See here:
So the type of patients that were in this study were the following :
So in this study of really clinically symptomatic patients CMR findings of both LGE and low LV systolic function was predictive of worse outcomes. But even here -- while 44% of patients had LGE on CMRI, only 15% of patients had adverse events.
This just means that finding nothing on a cardiac MRI is a lot more clinically useful than finding something on a cardiac MRI even in this very high risk group of patients (Negative predictive value >>> Positive predictive value)
For the author's of the current study to cite this particular study of highly symptomatic, high risk patients while trying to support CMR as an "excellent risk stratification tool" for clinically low risk, asymptomatic athletes is not just premature... its a bit dumbfounding..
The study the authors use 2 validate their abnormal MRI findings takes patients that are highly likely 2 have myocarditis clinically, and THEN finds an abnormality onMRI that shows some promise in predicting longer term serious outcomes. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506846/
Said another way: The prior cited study (that @venkmurthy is an author on!) used the clinical context to help validate what was found on cardiac MRI. You can't then use what's found on an MRI independent of the clinical context to make predictions on what the MRI findings mean!
A commonly used eg. of this logical misadventure is to conclude that since most car accidents occur within 25 miles from home, you are safest when you are far from home. The Probability of A given B, isn't the same as the Probability of B given A.
And as mentioned by others : @venkmurthy & @RogueRad already, the CMRI findings demonstrated in this most recent offering are also far more subtle than what's demonstrated in the older paper these authors are citing. (look at pics)
Summary:
1. Myocarditis is bad
2. Luckily it is rare
3. We think viruses are the most common cause of this rare, bad condition
4. We still have no evidence to suggest that Sars-COV2 is worse than any other virus when it comes to the heart
1. Myocarditis is bad
2. Luckily it is rare
3. We think viruses are the most common cause of this rare, bad condition
4. We still have no evidence to suggest that Sars-COV2 is worse than any other virus when it comes to the heart
5. The wealth of evidence to date from large outbreaks in the US & the world is that the virus does most of its damage in the lung
6. After 6 months, cardiology clinics in the US are not being overwhelmed with new heart failure diagnoses
6. After 6 months, cardiology clinics in the US are not being overwhelmed with new heart failure diagnoses
7. In the rare patients sick enough to be biopsied, the coronavirus is rarely found in cardiac myocytes
8. Other viruses have been reported to have the same cardiac MRI abnormalities seen here (LGE, abnormal T1/T2)
8. Other viruses have been reported to have the same cardiac MRI abnormalities seen here (LGE, abnormal T1/T2)
9. There is little addl information to glean from CMRI (or any imaging) case series of former COVID patients when we have no idea what the abnormal findings are predictive of. Recall - even in sick patients, an abnl CMRI didn't always lead to bad outcomes.
10. Please continue to study away in non-single arm long term studies that would take years to complete. There is nothing/nada/zilch to support the use of routine CMRIs in clinical practice.
Additional great comments https://twitter.com/roguerad/status/1304448861910503426
