College Football, Myocarditis and Covid-19

This may come as a surprise to many readers but the skeptical cardiologist is a huge fan of the University of Oklahoma college football team. Growing up in Oklahoma I developed life-long strong attachments to the Sooners, Woody Guthrie and Mickey Mantle. 

When you add my ties to the Ohio State Buckeyes you may understand why I am fascinated by the developments in college football during the COVID-19 era. The Big 10 athletic conference of which the Buckeyes are the most dominating team canceled their season earlier in August as did the Pac-12 conference.

The NY Times published an article last week entitled Doctors Enter College Football’s Politics, but Maybe Just for Show and to my surprise one of our cardiology trainees from the time I was a Professor at The Oho State University (Curt Daniels) played a key role in the Big 10 and Pac 12 decision.

Daniels, the director of sports cardiology at Ohio State, had also been busy, working to publish a three-month study whose preliminary findings were presented to Pac-12 and Big Ten leaders before they shut down football earlier this month.

 Daniels said that cardiac M.R.I.s, an expensive and sparingly used tool, revealed an alarmingly high rate of myocarditis — heart inflammation that can lead to cardiac arrest with exertion — among college athletes who had recovered from the coronavirus.

The survey found myocarditis in close to 15 percent of athletes who had the virus, almost all of whom experienced mild or no symptoms, Daniels added, perhaps shedding more light on the uncertainties about the short- and long-term effects the virus may have on athletes.

It’s important to note that Daniels’ study has not made it through the peer-review publication process thus we can’t yet check it for accuracy and validity

Myocarditis, Cardiac MRI and COVID-19

A published COVID-19 cardiac MRI study from Germany is what triggered me to write “It is now time to worry about cardiac consequences of COVID-19” a few weeks ago.

That study on non-athletes subjects with COVID-19 found frequent abnormalities by cardiac MRI months after the clinical infection had resolved. Since publication the German cMRI study was criticized appropriately on Twitter for sloppy data presentation and has been corrected online. For me, the main findings of the study and the concern it raises are still valid. But we need more data and more studies to know how important these early findings really are.

Professor Darrel Francis played a key role in the Twitter criticism of the German MRI paper. You can read his summary of an interview with the lead author that occurred after the paper was corrected.

It never occurred to me that this paper would cause the cancelation of the college football season yet it quickly rocketed into the national discussion.

Enter Ackerman

Things became interesting after a Mayo Clinic “genetic cardiologist” posted this on twitter

In Alabama and likely most SEC states Ackerman is now considered “the cardiologist who saved the college football season.

 if we have college football this fall, Dr. Ackerman will be one of the reasons why. His perspective on myocarditis, an inflammation of the heart, helped the Big 12 hold off on canceling its season, which would have set off a string of dominos that could have doomed college football last week. Without the Big 12, the ACC would have likely dropped out, and it would have been increasingly difficult for the SEC to move forward alone. The fate of the 2020 season hinged on the biggest wild card of the Power 5 conferences

For those readers not familiar with the landscape of college football I’d like to point out that the Oklahoma Sooners are the dominating team (at least on the field of play) in the Big 12 athletic conference.

The Al.com article goes on to detail Ackerman’s crucial role. Please note that his ability to utilize a sports analogy to convey his point to the athletic directors

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.

Whereas the study doesn’t prove that 18-24 year olds post COVID-19 would develop cardiac MRI abnormalities at the same rate as an older group there is also no reason to believe the virus would not create problems in that group.

Ackerman apparently is a master of the analogy:

He used a soup analogy to explain how to weigh myocarditis, among other COVID-19 related issues, in whether to play football this fall. The conferences that canceled their seasons, he explained, stirred myocarditis in as a primary ingredient into their soup and then declared the soup tasted bad. Ackerman advised the Big 12 and Conference USA leaders to take myocarditis out of that equation, and if they still felt like the soup tasted bad, then that was their reason to cancel.

I’m not sure what the soup analogy added to this discussion. Basically, the possibility of long-lasting cardiac damage is one of many factors that should be weighed.

“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.”

The evidence doesn’t say myocarditis is spooky but Ackerman must know that it can be a life-threatening disease. In fact, he went on to recommend a whole host of cardiac tests be done on players who contract COVID-19:

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’d be interested to know if Ackerman thinks everyone who contracts COVID-19 should get the raft of cardiac tests he has recommended or is this just for the more valuable athletes who play for free in college.

Such extensive testing, of course, raises a whole host of issues and concerns. False positives will be the predominant abnormalities identified. Thus, many of these athletes will be sidelined for minor elevations in their T1 relaxation time or slight changes on an EKG. Will Dr. Ackerman decide what abnormalities mandate rest for a player, potentially endangering a future professional career?

Pac-12: The Voice of Reason?

The only conference to publicly post their findings and analysis has been the Pac-12 in a document entitled “Health and Well Being Considerations for Pac-12 Institutions Guidance for Local Planning for Return to Sporting Activity: Updated 8/10/2020 “(see here.)

This appears to be a well-researched decision which occurred without the input of Dr. Ackerman.

The board of the Pac-12 Student-Athlete Health and Well-being Initiative (SAHWBI) has engaged in daily and weekly calls and discussions throughout the preceding five months reviewing and analyzing our continuously developing understanding of the COVID-19 pandemic. These recommendations have been created through this collaboration and are informed by Pac-12 SAHWBI physicians and athletic trainers as well as national experts in public health, infection disease, epidemiology, and cardiology.

Here are the three major reasons cited for the cancellation.

I think the Pac-12 description of the cardiac complications as a factor is accurate: this is new and evolving (as is all COVID-19 data) and most definitely potentially serious.

We are concerned about health outcomes related to the virus. Among these, there is new and evolving information regarding potential serious cardiac side effects in elite athletes. 

The 12-page document goes on to detail the processes and criteria that will be necessary to begin and continue a football season.

Apparently mask wearing even during active competition will be mandated.

Face coverings can be effective at reducing transmission of COVID-19. Face coverings should be used by student-athletes, coaches, and staff at all times when unable to socially distance, including during practice and competition; exceptions to this include when hydrating or drinking recovery fluid in a physically distanced manner. Face coverings provide some protection to the wearer and also may prevent an infected individual from spreading disease. Although uncomfortable to some, face coverings are not dangerous to those wearing them, even in the heat.

Is Oklahoma OK?

My Sooners are proceeding with the football season and start against Missouri State Sept. 12.

According to this Tweet they will have special helmets with masks built in.

Per SI.com Lincoln Riley, the Sooners young and brilliant head coach, has experimented with multiple different methods for covering the face of his Sooners:

“We’ve experimented with three things,” Riley said, “Cloth covering, which (is) effective, not bad as far as breathing. The big problem with that is vision. You just all of a sudden something covering you right here (over the eyes), it really limits the vision, which is different. 

“We’ve experimented with the plastic shield that’s over the face and the facemask. Again, breathing-wise, not awful there from what we’ve been told by our players. Biggest issue there is that fogging up, and then what’s your answer if you get in a game where it’s raining or you’re dealing with the elements.

“And then we’ve experimented with the normal masks, like our guys wear all other parts, just being on underneath the helmet. Probably had the most success with that, because it doesn’t get knocked off, you know, doesn’t fog up. I think our guys are getting used to having them on all the time.”

To Play Or Not To Play?

I can’t say I have the answer on whether college football should or should not proceed. Although I would love to watch my beloved Sooners score touchdown after touchdown on upcoming fall Saturday afternoons I would not want to see any players or fans put at risk of COVID-19 for that privilege.

These decisions are best made by transparent discussion between all shareholders similar to the Pac-12 SAHWBI physicians and athletic trainers as well as national experts in public health, infection disease, epidemiology, and cardiology.

Ideally, they should not be made on the basis of political or monetary calculations. Nor should one genetic cardiologist who happens to tweet what athletic directors want to hear (no matter his expertise with culinary and sports analogies) have an out-sized influence.

Ultimately, I see a path forward to reasonably safe resumption of college football utilizing the processes and criteria outlined in the Pac-12 document. As we learn more about the new and evolving threat of COVID-19 associated myocardial damage these processes and criteria will need to be modified.

Boomer Sooner Yours,

-ACP

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9 thoughts on “College Football, Myocarditis and Covid-19”

  1. What do you think now that the PSU director of athletic medics says that 30 to 35% of Big Ten athletes who had COVID-19 show myocarditis:

    “ that cardiac MRI scans revealed that approximately a third of Big Ten athletes who tested positive for COVID-19 appeared to have myocarditis

    Reply
    • Like the Ohio State data, I’d like to look at their data and see it after a peer review process.
      I looked at some of the video that the article christian (earlier comment) linked to.
      the PSU doctor mentions Michael Ojo, ex-FSU basketball player who had sudden death while practicing after experiencing coronarvirus in the off-season.
      it seems like that death is influencing the Big 12 decision-making.

      Reply
  2. Pretty interesting to see how this is playing out now with the Penn State data coming in with 30-35% of players testing positive for Covid now being diagnosed with myocarditis through CMR (that 30-35% includes those who were asymptomatic as well). Your concern from the initial data from the german CMR study you wrote about it seems is getting more validated by the day and the data! Who would have thought college sports could offer research that could impact the understanding of COVID infections.

    https://www.centredaily.com/sports/college/penn-state-university/psu-football/article245448050.html

    Reply
  3. Dr. Pearson-
    My mom still lives in Bartlesville, so our son, now 31, made plenty of trips with us from (his) native state of Texas to visit his OK grandmother. He became an OU football fan quite young, and has remained devoted to them, despite constant ragging from his friends, all UT fans. BOOMER SOONER! Wish we still had the 50-yard-line tickets my dad got from OU when he was a State Representative in the 1960s-70s for son to use.

    Reply
  4. This Covid thing sounds eerily similar to what I endured – and hence why I’m on your site – back in Jan of 2019. Not Jan of 2020.

    A year before all this started.

    Sickest I’ve ever felt in my life. On Jan 2, 2019 I suddenly developed a really nagging dry cough while on the phone with some co-workers. even they commented on how bad it sounded. The next day the paramedics were in my bedroom stating, “Well, we think you have the flu, but your heart is doing some strange stuff so we think you should go to the ER just to be safe.” So off I went.

    While in the ER I got worse. Heart rate silly high (140bpm) and an x-ray that looked like rain clouds. They take me for a CT Scan.

    Take a look at it here – http://ajawamnet.com/ctscan.jpg

    Huh… looks real similar to what the news now states about covid. Interesting

    So while in the ER they notice that my left ventricle is silly enlarged. “You’re a really sick man..” is what one of the ER doc’s stated. My pulseox is down to the mid 80’s and I’m on O2…

    Flue test – negative…

    So I get thru it some how (if ever on oxygen ask for a bubbler – that med gas is dry as a bone commin’ out of the wall) and meet a cardio the next day. By then my heart rates in the low 100’s and I ask to get the f’ out of there. The staff sucked, the care was sub-par at best. The cardio Dr. says yea you can leave but you need to get a cath.

    So I do. Totally clear. But my EF is 15-20%. But I have no edema, never did. They have no clue – call it myocardidtis.

    In the next few months I’m told to limit my fluid intake to the typical 1500mL.. So I do

    End up in the ER three more times with Afib. And haven’t pissed normally since the incident.

    So finally on the third trip the one older ER doc states that I’m dangerously dehydrated and proceeds to put two large IV bottles of fluid in my with in a few hours. Finally got my BP up over 100.

    So here I sit, still wondering what I had that caused all this, reading the reports of the diagnosis and long term effect of CoV2.

    And it all sounding really familiar…

    Reply
  5. There was a study recently published about the effect on cardiomyocytes of convalescent patients with COVID-19 https://www.biorxiv.org/content/10.1101/2020.08.25.265561v1.full.pdf . The researchers outlined some interesting observations about cytokine involvement however one the most interesting revelations seemed to be the disruption of sarcomeres in the cardiomyocytes themselves, leaving them fragmented, Another observation was the lack of nuclear DNA in the cardiomyoctyes which contributed to their lack of function. I have read elsewhere, I am forgetting the source so it take with a grain of salt that researchers might have miscategorized or least misunderstood COVID as only a respiratory virus when in fact it might possess cardiotropic viral characteristics. I’m curious to see if further studies will reproduce the findings of the researchers from this study and the german CMR study. I also wonder what the ramifications are for treatment, what would necessitate a further diagnostic like CMR to investigate the possibility of myocarditis and will insurance cover this or will this be out of pocket? Can cardiotropic viruses attach to cardiac pacemaker cells? That would be scary if this virus could.

    Reply
  6. No wonder I feel a connection to what youu write: I, too, went to Ohio State med school, internship, residency (old terminology) & then did my Cardiol wi Willis Hurst/Bob Schlant/BruceLogue at Emory! Echo wi strain/rate would likely be as effective as cardiac MRI & a helluva lot less cher. I suspect if cardiac MRIs were done in multiple other viral illnesses, the EXACT SAME MYOCARDIAL findings would often be present as happens wi CoV2-19. You might enjoy the Summary Corona Virus Update at http://www.thepmc.org. HRS, MD, FACC

    Reply

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