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As the kicked off with its first game Thursday evening and college football gets going in earnest, yet more data emerged on the myocarditis risk of COVID-19 in athletes.

Of 26 competitive athletes at Ohio State University scanned with cardiac MRI (CMR) after asymptomatic or mild cases of COVID-19, four (15%) had findings suggestive of myocarditis. Two of these had pericardial effusion; two had shortness of breath, while the others had no symptoms of myocarditis.

Another eight athletes (30.8%) had late gadolinium enhancement (LGE) without T2 elevation, suggestive of prior myocardial injury, Saurabh Rajpal, MBBS, MD, of Ohio State in Columbus, and colleagues .

The Ohio State connection is ironic. Ohio's attorney general has hinted that , of which it is a member, if the fall football season is finally cancelled. Conference officials have cited studies pointing to COVID-related myocarditis risk for athletes as an important factor in the decision.

Notably, the new study couldn't conclusively say COVID-19 caused the scar tissue seen in the eight and didn't address whether these athletes were safe to return to play; its main focus was on usefulness of the imaging technology for myocarditis rule-out.

But the researchers wrote that CMR could potentially separate a high-risk group from those athletes safe for participation, "because CMR mapping techniques have a high negative predictive value to rule out myocarditis."

Post-COVID CMR data have been used to support on opening the football season and other competitive sports, although the senior author of perhaps the most cited study argued that the evidence is more important on a population level than for individual decisions.

These findings, which had been in the media, are the first to be published from a series on competitive athletes post-COVID-19.

"It is very nice to see these results described in print with quite a lot of detail in the tables so we all can read and digest it," commented Venkatesh Murthy, MD, PhD, a radiologist at the Frankel Cardiovascular Center of the University of Michigan in Ann Arbor.

"My concerns are that there is no control group, and overall it appears that many of the findings are subtle or mild. We don't know what the clinical significance of these findings is, nor if they will remain abnormal, worsen, or regress if one is re-imaged in the future," he cautioned. "Also, it does not appear there was a strong relationship between T1 findings emphasized in prior work and meeting MRI criteria for myocarditis."

Rajpal's group based their determination of myocarditis on presence of two main features of the updated Lake Louise Criteria -- myocardial edema indicated by T2 and myocardial injury indicated by nonischemic LGE.

Generalizability or how representative the sample might be was unclear. The sample was all competitive athletes referred to the sports medicine clinic after testing positive for COVID-19 at Ohio State this summer. Their mean age was 19.5 years; 58% were male; and they competed in football, soccer, lacrosse, basketball, and track.

Outside of COVID-19, as Gregg Fonarow, MD, of UCLA, , no subendocardial, transmural, or subepicardial LGE patterns or findings consistent with myocarditis turned up in in a study in the Journal of Cardiovascular Magnetic Resonance.

"Athletic cardiac adaptation could be responsible for these abnormalities" seen in the Ohio State cohort, Rajpal's group wrote. However, they argued that the higher mean T2 in this cohort (59 ms with suspected myocarditis vs 51 ms in those without it) favored pathology. "Additionally, the rate of LGE (42%) is higher than in previously described normative populations."

The panel of tests run on the 26 student athletes turned up no diagnostic ST/T wave changes on electrocardiogram or elevated serum troponin I. Ventricular volumes and function were within the normal range in all of them on transthoracic echo and CMR.

The researchers called for long-term follow-up and large-scale studies with population control groups to understand the prognostic significance of the myocarditis and mild myocardial injury seen after COVID-19.

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