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Myocarditis thread - OutsiderFan - 08-11-2020
Given the growing significance of Myocarditis as a Covid-19 side effect, and the fact that though a significant variable in the College Sports discussion, it has broader implications, I thought a thread dedicated to Myocarditis would make sense.
Assumption
We have seen research show those diagnosed with Covid-19 have a higher propensity of Myocarditis than is expected in the population.
Questions
1. Do we have enough MRI scans of people who haven't had Covid-19 to compare as a control group, and accurately conclude Covid-19 is reason for increased Myocarditis?
2. Do we have any studies showing no Myocarditis before Covid-19 and having it after, in enough numbers to show causation?
3. Is it only a matter of time before all infected by Covid-19 develop Myocarditis?
4. BC mentioned two types exist. What is the Covid-19 one? More or less problematic?
5. Will it go away, or is it a permanent condition?
6. If permanent, is there any data on long-term health and life expectancy with those who have Covid Myocarditis?
7. How do you manage having Covid Myocarditis and is it best to shut down athletic activity like Eduardo Rodriguez was by the Red Sox?
8. Can you do extra damage to your heart by exerting yourself while having Myocarditis and not knowing it?
RE: Myocarditis thread - needle - 08-11-2020
(08-11-2020, 05:36 AM)OutsiderFan Wrote: Given the growing significance of Myocarditis as a Covid-19 side effect, and the fact that though a significant variable in the College Sports discussion, it has broader implications, I thought a thread dedicated to Myocarditis would make sense.
Assumption
We have seen research show those diagnosed with Covid-19 have a higher propensity of Myocarditis than is expected in the population.
Questions
1. Do we have enough MRI scans of people who haven't had Covid-19 to compare as a control group, and accurately conclude Covid-19 is reason for increased Myocarditis?
2. Do we have any studies showing no Myocarditis before Covid-19 and having it after, in enough numbers to show causation?
3. Is it only a matter of time before all infected by Covid-19 develop Myocarditis?
4. BC mentioned two types exist. What is the Covid-19 one? More or less problematic?
5. Will it go away, or is it a permanent condition?
6. If permanent, is there any data on long-term health and life expectancy with those who have Covid Myocarditis?
7. How do you manage having Covid Myocarditis and is it best to shut down athletic activity like Eduardo Rodriguez was by the Red Sox?
8. Can you do extra damage to your heart by exerting yourself while having Myocarditis and not knowing it?
I may be way off on this, but my understanding is that, in general, myocarditis is poorly understood.
Quote:Myocarditis is a challenging, difficult condition. It is "rarely recognized, the pathophysiology is poorly understood, there is no commonly accepted diagnostic gold standard, and all current treatment is controversial," wrote Drs. Kenneth L. Baughman of Harvard Medical School and Joshua Wynne of Wayne State University in the introduction to their chapter on myocarditis in Braunwald's Heart Disease, an influential textbook.
https://www.health.harvard.edu/newsletter_article/Heart-infection-can-pose-a-medical-mystery
RE: Myocarditis thread - BostonCard - 08-11-2020
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 1. Do we have enough MRI scans of people who haven't had Covid-19 to compare as a control group, and accurately conclude Covid-19 is reason for increased Myocarditis?Yes. Cardiac MRIs are not common, but the technology has been around long enough that scans of healthy people exist for comparison.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 2. Do we have any studies showing no Myocarditis before Covid-19 and having it after, in enough numbers to show causation?No, because the procedure is not commonly done, particularly in healthy people, it's unlikely that anyone happened to have had an MRI done, but because the condition is fairly rare, you wouldn't expect any meaningful myocarditis pre-COVID.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 3. Is it only a matter of time before all infected by Covid-19 develop Myocarditis?No. It is unlikely that all patients with COVID-19 will develop myocarditis.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 4. BC mentioned two types exist. What is the Covid-19 one? More or less problematic?
Not sure what you meant by "two types". I mentioned that we are not sure if the mechanism is direct myocardial infection by COVID-19, or the effect of systemic inflammation that is turned on by COVID-19. We don't have a ton of information about the pathophysiology of COVID-19 induced myocarditis.
Direct viral infection of the heart is probably a bit scarrier, based on the fact that viral myocarditis, when it occurs, can be severe enough to require a heart transplant.
Here's a figure from the European Society of Cardiology:
![[Image: Figure_03.jpg]](https://www.escardio.org/static-file/Escardio/Medias/education/covid-19/Guidance-Document/Figure_03.jpg)
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 5. Will it go away, or is it a permanent condition?
I don't think we know yet.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 6. If permanent, is there any data on long-term health and life expectancy with those who have Covid Myocarditis?Probably a range between "asymptomatic" and "death/requiring heart transplant". Not to be glib about it, but just as COVID-19 itself, there is likely going to be a brobdingnagian range. Most of what we know is based on short term outcomes, and biomarkers of cardiovascular injury are associated with worse outcomes during the acute phases.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 7. How do you manage having Covid Myocarditis and is it best to shut down athletic activity like Eduardo Rodriguez was by the Red Sox?I think there is a cardiologist lurking on the board (who posted at least once). Hoping he will pipe in here.
(08-11-2020, 05:36 AM)OutsiderFan Wrote: 8. Can you do extra damage to your heart by exerting yourself while having Myocarditis and not knowing it?I'd punt this to the cardiologist as well. I think moderate exercise is probably ok, but strenuous exercise might be risky.
For what it is worth, both the American College of Cardiology and the European Society of Cardiology have COVID-19 guidelines. A lot of it is focused on the acute effects, but they touch on chronic effects.
https://www.acc.org/latest-in-cardiology/features/accs-coronavirus-disease-2019-covid-19-hub#sort=%40fcommonsortdate90022%20descending
https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance
BC
RE: Myocarditis thread - OutsiderFan - 08-11-2020
Thanks, BC for the awesome insight. Really good information provided!
RE: Myocarditis thread - 82lsju - 08-11-2020
Quote:Myocarditis emerged as a significant health concern that largely led to the Big Ten's decision. The condition involves an inflammation of the heart muscle. It can reduce the heart's ability to pump, causing rapid or abnormal heartbeat.
At least 15 Big Ten players have been left with myocarditis after contracting COVID-19, according to a high-ranking source within the Big Ten.
"Myocarditis is the ballgame right now," the source said. "Myocarditis is the major issue they're looking at. … Between the Pac-12 and the Big Ten, that's what is really driving the push to push this off to spring."
https://www.cbssports.com/college-football/news/big-ten-cancels-college-football-season-for-fall-2020-hopes-to-play-in-spring-2021/?#:~:text=Following%20a%20morning%20meeting%20of,amid%20the%20COVID%2D19%20pandemic
RE: Myocarditis thread - fullmetal - 08-11-2020
I'm hearing that the ejection fraction is statistically unchanged between populations with and without covid-induced myocarditis, for whatever that's worth. Clearly none of the myocarditic population have been enduring high-level athletic training since their bout with covid.
RE: Myocarditis thread - OutsiderFan - 08-12-2020
After reading the American College of Cardiology website, my laymen's interpretation:
We must do a lot of testing for Covid-19 to find where the virus is. Then, on top of that, it's a new pathogen with long-term complications nobody understands. Now, here comes the fact Myocarditis routinely develops as a complication from Covid-19. This too requires testing to see who might have developed Myocarditis. A simple blood test can identify Tropinin protein levels in the blood (the higher the level, the more likely Myocarditis exists), but MRIs may also be required to confirm diagnosis.
Myocarditis is mild in most cases, but the Mayo Clinic says this:
Quote:In many cases, myocarditis improves on its own or with treatment, leading to a complete recovery. Myocarditis treatment focuses on the cause and the symptoms, such as heart failure. In mild cases, persons should avoid competitive sports for at least three to six months.
RE: Myocarditis thread - BostonCard - 08-19-2020
This is an interesting perspective:
https://www.al.com/alabamafootball/2020/08/how-a-cardiologist-may-have-saved-the-college-football-season.html
I don't know of Ackerman, and I think questioning how applicable findings from a study in middle aged Germans applies to young athletes is reasonable. I would not be at all surprised if the incidence of myocarditis is lower in younger people, just as the disease in general is less severe in younger people. On the other hand, I'm not so sure I would totally dismiss the concern just because it wasn't a study of young athletes. To some degree, all of medicine is an extrapolation for which the precise study relevant to the patient you have in front of you may not exist. You could reasonably say that given the potential seriousness of myocarditis, that until we can rule out an unacceptable risk for athletes that we shouldn't.
Quote:The Minnesota-based cardiologist leads the Windland Smith Rice Sudden Death Genomics Lab which studies, among other things, sudden death in young athletes. He explained to the Big 12′s leaders that a new myocarditis study in the Journal of American Medical Association that sparked panic across college sports didn’t have the “bandwidth” to be transferable in a useful way. The study, conducted in Germany and composed of middle-aged adults, found that 78 percent of the 100 participants had some cardiac abnormality. Ackerman said it’d be a “scientific foul” to infer that those findings are relevant for 18 to 24-year old athletes.
"You cannot make that leap," Ackerman exclaimed.
"There's just too many unknowns to say we have new damaging, alarming evidence that COVID-19 myocarditis is the big, bad spooky thing in town now, and we need to do something about it," Ackerman said. "Not new news at all; we've known that this virus can affect the heart muscle for five months now. It's not new, it just got put forward in a new way, and it's taken on a new life."
That is a reasonable position, of course. But it would also be reasonable to say that in the absence of evidence that it is not relevant to 18 to 24-year old athletes, the better part of valor would be to postpone a season that is not essential.
And to be fair, Ackerman proposes some reasonable risk reduction measures:
Quote:Ackerman pushed for the Big 12 to consider additional heart-related protocols to mitigate any possible risks, with the conference adopting plans to test athletes who had the coronavirus with an EKG, cardiac MRI, echocardiogram and troponin blood test. He stressed that any player who contracts COVID-19 needs to have a “squeaky clean cardiac evaluation” before getting the go-ahead to return to play. He cautioned them to consider possible mental health ramifications of canceling a season, referencing past experiences with athletes who suffered after being medically disqualified for heart issues.
I think we have a cardiologist lurking on this board, so I'd be interested in their point of view, but a plan where you have adequate testing and athletes with positive tests undergo a thorough cardiac evaluation strikes me as a reasonable risk mitigation measure.
BC
RE: Myocarditis thread - BostonCard - 09-12-2020
Four of 26 Ohio State athletes with COVID-19 had "findings suggestive" of myocarditis (and another 8 had evidence of prior myocarditis), though I still wonder how clinically significant it is.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645?alert=article
The article does state: "Cardiac magnetic resonance imaging evidence of myocardial inflammation has been associated with poor outcomes, including myocardial dysfunction and mortality." But this was a very different patient population (not even one with COVID-19), so it is hard to know how much it will translate to athletes who get COVID-19 associated myocarditis.
BC
RE: Myocarditis thread - DocSavage87 - 09-19-2020
https://science.sciencemag.org/content/369/6510/1414
Viral heart damage under scrutiny
This fall, cardiologist Sam Mohiddin will embrace a new role—that of research subject. MRI scans of his heart at St. Bartholomew's Hospital in London, where he works, will help answer a pressing question: Do people who suffered a mild or moderate bout of COVID-19 months ago, as he did, need to worry about their heart health?
Fears that COVID-19 can cause the cardiac inflammation called myocarditis have grown, as doctors report seeing previously healthy people whose COVID-19 experience is trailed by myocarditis-induced heart failure. Mohiddin recently treated 42-year-old Abul Kashem, who had typical COVID-19 symptoms in April, including loss of smell and mild shortness of breath. A month later, he fell critically ill from severe myocarditis. “I'm just grateful to be alive,” says Kashem, who spent more than 2 weeks in an intensive care unit. Why did this happen? he wonders.
How the virus might damage heart muscle is just one question researchers are now probing. Other studies are following people during and after acute illness to learn how common heart inflammation is after COVID-19, how long it lingers, and whether it responds to specific treatments. Researchers also want to know whether patients fare similarly to those with myocarditis from other causes, which can include chemotherapy and other viruses. In more than half of virus-induced cases, the inflammation resolves without incident.
But some cases lead to arrhythmia and impaired heart function, or, rarely, the need for a heart transplant. Because millions are now contracting the coronavirus, even a small proportion who suffer severe myocarditis would amount to a lot of people. “Are we going to have an increase of patients with heart failure secondary to this?” asks Peter Liu, a cardiologist and chief scientific officer of the University of Ottawa Heart Institute.
Whether SARS-CoV-2, the virus that causes COVID-19, induces cardiac injury including myocarditis more often, or with greater severity, than other viruses is still unclear. Because SARS-CoV-2 can trigger an intense immune response throughout the body, survivors may be at heightened risk of cardiac inflammation. Another idea suggests COVID-19 patients might be prone to the condition because the virus enters cells by binding with the angiotensin-converting enzyme 2 (ACE2) receptor, which sits on heart muscle cells. But researchers caution against outrunning the data. “It's a good hypothesis, but it's not a tested one,” says Leslie Cooper, a cardiologist at the Mayo Clinic in Jacksonville, Florida, about ACE2.
One reason it's hard to say whether COVID-19 poses a special risk of myocarditis is uncertainty about its prevalence after other infections. Echocardiogram studies after some influenza outbreaks suggest up to 10% of flu patients have transient heart abnormalities, Liu says. But such studies are scarce. “We don't scan patients after they had the flu,” says Valentina Püntmann, a cardiologist at University Hospital Frankfurt.
Püntmann fueled concerns about myocarditis when she did just that with COVID-19 patients. Her team used MRI to scan the hearts of 100 COVID-19 patients an average of 71 days after they had tested positive. The scans showed cardiac abnormalities in 78 people, with 60 appearing to have active inflammation. Most also described lingering symptoms, such as fatigue and mild shortness of breath, leading Püntmann to wonder whether heart inflammation might be responsible.
Although the work by Püntmann and her colleagues, published in July in JAMA Cardiology, prompted alarming headlines, many researchers say it needs to be replicated. Cardiologists urge anyone with symptoms like shortness of breath or chest discomfort after COVID-19 to see a doctor, but they worry about a flood of healthy recovered people clamoring for heart assessments. “Here's the good news: We're going to find out” how likely cardiac injury is, says Matthew Martinez, director of sports cardiology at Morristown Medical Center.
Because of the physical demands of sports, team doctors need to be on guard for myocarditis. A paper in JAMA Cardiology last week reported a study of 26 athletes at Ohio State University after COVID-19; four had developed myocarditis. Professional sports leagues are also scanning the hearts of athletes who were infected with SARS-CoV-2. Those with myocarditis, regardless of whether they have symptoms, are benched, in part out of fear that myocarditis could lead to sudden death during intense activity. Martinez, who's helping coordinate the research for the National Basketball Association and Major League Soccer, predicts a flow of data on athletes over the coming months. “Those of us in this space are willing to ruin a Saturday or a Sunday to get this done.”
He stresses, though, that even if researchers can clarify the average duration of myocarditis and its risks for a young athlete, those may be very different for a 50-year-old with obesity or high blood pressure, especially if they were sick enough with COVID-19 to be hospitalized. “In those individuals, I am going to be more cautious” and screen for heart injury, he says.
Others are pursuing clues to how COVID-19 can damage the heart, which might point to ways to head off the damage. “SARS-CoV-2 does challenge your immune system in unconventional ways,” Liu says. Autopsies of heart tissue after COVID-19 have revealed inflammation in the heart's blood vessels instead of its muscle cells, the site of the inflammation caused by other infections. Another autopsy study found scattered death of heart cells, but the authors noted the mechanism of injury was unknown. “There's been a lot of discussion whether this is myocarditis” as typically defined, Liu says. Regardless, he and others hope for clinical trials to test whether preventive strategies, such as taking beta blocker drugs, might head off heart failure in someone flagged as high risk after COVID-19.
While Mohiddin volunteers for a study of survivors, he's also running one: a trial that aims to recruit 140 people while they are hospitalized with COVID-19 or soon after, 20 with severe myocarditis and the rest without. He and colleagues will look for abnormal T cell levels in the blood of people with myocarditis, which could help explain whether and how the immune system is causing cardiac injury. He is also exploring whether immune cell patterns in the blood presage myocarditis later.
Even if COVID-19 rarely causes serious myocarditis, one hypothesis is that mild cases could heighten the risk of heart disease years later. Scar tissue can form as myocarditis heals, and earlier work has shown residual cardiac inflammation portends worse heart health. As cardiologists, “We're in the business of identifying asymptomatic risk factors,” such as hypertension, Mohiddin says. “It's not difficult to imagine that in the future, clinical practitioners will ask a new patient, ‘Did you have COVID?’”
RE: Myocarditis thread - needle - 09-21-2020
Quote:The question now is: What to do about the people who have subclinical myocarditis after COVID-19, which presents with no symptoms and can be seen only on a medical scanner? Chokshi, the sports cardiologist, says the risk that these abnormalities will lead to heart failure “is very, very low,” but “the outcome is catastrophic.”
https://www.theatlantic.com/health/archive/2020/09/covid-19-heart-pandemic-coronavirus-myocarditis/616420/