Myocarditis – What is that?

On Monday the college sports world was rocked by a statement by Penn States Director of Athletic Medicine where he initially said that 30-35% of Big 10 athletes who tested positive for COVID-19 appeared to have myocarditis.

Penn State's director of athletic medicine says that MRI scans revealed that around 30-35% of Big Ten athletes who tested positive for COVID-19 appeared to have myocarditis, a type of inflammation of the heart muscle pic.twitter.com/LWXtsubopN

— Bleacher Report (@BleacherReport) September 3, 2020

This is an extremely worrisome statement given the fact that this is a contributing cause in the sudden cardiac death of many world-class athletes over the years. Last night the statement was revised to say that no Penn State athletes had been diagnosed with myocarditis.

What is Myocarditis?

Myocarditis is an important cause of arrhythmias and sudden cardiac death in both physically active individuals and athletes as well as members of the general population. Myocarditis is an inflammation of the heart muscle. This inflammation can be mild and resolve without intervention or can be more detrimental and lead to long-term cardiac involvement.

There are many different types of myocarditis and a wide range of possible agents that can trigger the disease. Examples include:

Viral: Common cold Adenovirus, coronavirus including COVID-19, influenza, and many others
Bacterial: Streptococci and meningococci to name a few
Fungal and parasites
Lymphocytic and Eosinophilic: Heart muscle infiltrated with different types of white blood cells
Autoimmune: Caused by autoimmune diseases, such as lupus and rheumatoid arthritis
Idiopathic: Inflammatory process in the heart muscle with no known cause

Many of the signs and symptoms of myocarditis match those associated with many viral illnesses including COVID-19. These symptoms include:

chest pain and /or chest discomfort,
shortness of breath,
heart rhythm disturbances (arrhythmias) and palpitations.
viral illness symptoms including fever, chills, fatigue, and aches
swelling of hands and feet without reason

Why Are Athletes More Susceptible?

Elite athletes seem to have an increased risk for viral infection in general and subsequent myocarditis due to increased exposure to pathogens brought on by their worldwide traveling and/or international competition. In addition, many athletes have impaired immune systems because they continue to train during infections and/or resume training early after a viral infection, strenuous exercise regimes or competitions, and exercise or play their sport in extreme weather conditions.

Diagnosis and Prognosis

Initial clinical presentation is variable, but athletes characteristically express non-specific symptoms of fatigue, muscle soreness, increased heart rate at rest, as well as during exercise and reduced overall exercise capacity. They generally feel done in by a day of exertion that previously did not bother them. Athletes with these symptoms need to speak up and be further evaluated by medical staff.

Most people who contract acute myocarditis will recover without further treatment. In most cases, they are able to resume competitive activities fairly quickly with most fully recovering and resuming previous activities within six months.

While the identification of increased incidence of myocarditis in COVID-19 patients is concerning, much more investigation is needed. With this being a novel virus, we are just starting to investigate this aspect of the condition and will continue to do so for the foreseeable future. At present, the ability to return to participation will need to be based on examination and evaluation by qualified medical staff and the athletes speaking up with any unusual symptoms.