by Jessica Pasley
Two days after Vanderbilt Commodores women’s basketball guard Demi Washington completed her 10-day isolation for COVID-19, she underwent a cardiac magnetic resonance imaging test (MRI).
The cardiac MRI was the last step Vanderbilt Athletics needed to ensure a safe return to playing for Washington, who was eager to return to the court.
It’s an extra step that may have saved Washington’s life.
“I had a mild case of COVID,” said Washington. “All the testing required by the SEC Conference was done and everything checked out fine.
“During an appointment after my MRI, I was told I had myocarditis and immediately I was in tears. I was in disbelief with a hundred thoughts and questions racing through my head. Is this something where I have to put the basketball down forever? Is there something I did to make this happen?”
Washington, a four-star recruit, was crushed when told she would have to sit out the remainder of the 2020-2021 season.
But her disappointment turned to appreciation once learning that the final test was not a requirement, but part of Vanderbilt’s protocol for athletes who tested positive for COVID-19. Cardiac MRI is not a part of the standard screening tests utilized by many athletic programs across the country.
But it is the only test that identified myocarditis in Washington.
It is well documented that COVID-19 may affect the heart. Viral infection is the most common cause of myocarditis, a disorder of abnormal inflammation of the heart muscle and is a leading cause of sudden cardiac death among athletes.
In a letter published in the December issue of the American Heart Association’s medical journal Circulation, a group of researchers at Vanderbilt University Medical Center highlighted the importance of considering cardiac MRI in addition to traditional screening measures to detect myocarditis.
The Vanderbilt study, COVID-19 Myocardial Pathology Evaluation in AthleTEs with Cardiac Magnetic Resonance (COMPETE CMR), also found a much lower degree of myocarditis in athletes than what was previously reported in other studies.
The study evaluated 59 Vanderbilt University athletes and compared them to a healthy control group as well as a group of 60 athletic controls.
The findings show the degree of myocarditis found by cardiac MRI in Vanderbilt athletes was only 3%. A more in-depth screening, doubling the number of participants, showed the same findings, which is very good news.
But disappointing news surfaced.
“None of the other screening tests helped us to identify the athletes with myocarditis,” said Dan Clark, MD, MPH, first author of the report and instructor of Cardiovascular Medicine at VUMC. “Initially, we hoped that the standard screening tests for athletes would be sensitive for COVID-19-related myocarditis because we wanted something that was widely available and quick.
“We hoped that a cardiac MRI would only be used if absolutely necessary,” said Clark. “However, their blood work, clinical exams, EKG, echocardiograms and other cardiovascular screening were normal. All of those traditional screening results would have led us to agree to allow some athletes to participate in a sporting event or practice, while the MRI told a different story.”
One that Washington is glad she can share today.
“I might be out on the court right now if I was not at Vanderbilt,” admitted Washington. “It’s so important that every person associated with student athletes be aware of the benefits of doing a cardiac MRI. And as athletes, we need to know more and advocate for ourselves.
“We always think these kinds of things won’t happen to you. But when it does, you want all of those extra steps taken,” she stressed.
“It’s always better to be safer than having to say, ‘I’m sorry.’”
While Washington does not require pharmaceutical or other medical intervention for myocarditis, she must adhere to a three-month, low-activity regime and continue her regular checkups. In March, she will undergo another MRI to check her status.
COMPETE CMR data also demonstrated more scarring in healthy heart muscle than expected, which led the group to dig deeper and compare a healthy, athletic population with normal cardiac MRI values against those who had recovered from COVID.
The athletic control group without COVID showed 24% (1 in 4) scarring in the heart muscle while the COVID athlete group had a 27% (1 in 4) scarring ratio. According to Clark, athletes commonly have a small area of benign scarring due to athletic remodeling. This scarring related to athletic changes was evident in both athletic groups studied.
“This particular piece of information is very important to share — myocarditis after COVID-19 tends to be in a similar spot,” he said. “Without the knowledge that this area of scarring is common in healthy athletes, clinicians could attribute the scarring to consequences from COVID-19. Those assumptions might unnecessarily restrict some athletes from competition.”
The findings suggest that the addition of cardiac MRI as an assessment tool for athletes may be very helpful in determining safe return-to-play guidelines.
COMPETE CMR, to be published in the February issue of Circulation, is the first study that the group is aware of to use an appropriate athletic control group to assess athletes after COVID-19.
“Myocarditis after recovery from COVID-19 is less common in athletes than we had feared,” said Sean Hughes, MD, director of the Vanderbilt CMR Laboratory and a co-senior author of COMPETE CMR. “Comparison to a healthy athletic control group without COVID was critically important to show that some changes on a cardiac MRI are related to athleticism and not COVID-19. However, despite the lower risk of myocarditis than expected, cardiac MRI remains a very useful tool for evaluating competitive athletes prior to a return to sports.”
Symptoms of myocarditis can include shortness of breath, chest pain, decreased ability to exercise and an irregular heartbeat.
“I know myself,” said Washington. “If I was back on the court and my heart was pounding, I would’ve pushed through it. I would have thought I was just out of shape and needed to go harder. This has all been a learning experience and, moving forward, I will have a better awareness.”
