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College Football, Myocarditis, and COVID-19

— The Skeptical Cardiologist weighs in on the risk

by

MedpageToday
Photo of a college football with a surgical mask.

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 its season earlier in August, as did the Pac-12 conference.

The New York Times published an article last week entitled To my surprise, one of our cardiology trainees from the time I was a professor at The Ohio State University (Curt Daniels) played a key role in the Big 10 and Pac 12 decision. The Times wrote:

"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's 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 a few weeks ago.

That study on non-athletes 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.

Darrel Francis, MD, 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 cancellation 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 John Talty wrote on AL.com:

"[I]f 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 went on to detail Ackerman's crucial role. Please note 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 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 ).

This appears to be a well-researched decision that occurred without the input of Ackerman. It said:

"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.

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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 September 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 in exchange 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.

Anthony C. Pearson, MD, is a noninvasive cardiologist and professor of medicine at St. Louis University School of Medicine. He blogs on nutrition, cardiac testing, quackery, and other things worthy of skepticism at , where a version of this post first appeared.