New on Sports Illustrated: Small Percentage of Big Ten Athletes Found to Have Myocarditis After COVID-19

About 30% of Big Ten athletes tested positive for COVID-19 last year and less than 1% of them were found to have clinical myocarditis, according to a study.

About 30% of Big Ten athletes tested positive for COVID-19 last year and less than 1% of them were found to have clinical myocarditis, an inflammation of the heart and the primary reason the conference decided to originally

scrap playing a 2020 fall football season.

The data is from a long-awaited study of Big Ten teams, obtained earlier this week by Sports Illustrated and published Thursday in the Journal of the American Medical Association (JAMA). The study features some of the most extensive and comprehensive data yet on college athletes’ cardiac impacts from contracting the virus, sports cardiologists say. The research also unveils a closely guarded topic among NCAA schools: the number of athletes to have tested positive for COVID.

From last March to December, more than 2,810 athletes tested positive for the virus in 13 of the 14 Big Ten schools to participate in the study—an overall positivity rate of 30.4%. The rate ranged from 13% at one school to 48.2% at another.

Of those to test positive, 1,597 athletes underwent a four-step, return-to-play cardiac evaluation that included a blood test, echocardiogram, EKG and cardiac MRI. Of those, 37 athletes were found to have clinical myocarditis or subclinical myocarditis, which the study defines as probable or possible myocarditis based on testing abnormalities.

Nine of the athletes had clinical myocarditis, a 0.56% clip that is similar to two studies recently released—one from a variety of NCAA schools and the other from professional sports leagues. Eight of the nine experienced chest pain, with three of those having heart palpitations.

Sports cardiology experts who spoke to SI describe the study as reassuring and positive news for the future of college sports in a COVID world.

“The other piece of info that is really reassuring is, with all these data sets of over 5,000 athletes, we haven’t seen adverse events in athletes. We haven’t seen sudden cardiac deaths. That really applies worldwide,” says Dermot Phelan, director of sports cardiology at Atrium Health in Charlotte, N.C., and a consultant with the NFL, NBA and NCAA.

The myocarditis scare swept across college sports last fall. The disease, found for years in people, was a significant factor in initial decisions by four FBS conferences to postpone the 2020 fall football season, most notably the Big Ten. Conference leaders voted Aug. 11 to push the football season to spring before re-examining the issue and reversing course roughly six weeks later on recommendations from its medical advisory board—the same board that had originally thought it too dangerous to play in the fall.

Big Ten medical experts are now exploring whether they should conduct cardiac MRIs on all COVID-19 positive athletes after the emergence of the study. The Big Ten is believed to be the only FBS conference that still incorporates cardiac MRIs in their return-to-play protocols for those who tested positive for the virus.

“We are in meetings about that as the study comes out,” says Curt Daniels, the lead author of the study and a sports cardiologist at Ohio State. “Is it going to adjust our protocol? Our hope is not recommending MRI for all. We haven’t made any determination yet.”

Daniels says there are return-to-play “pathways” outside of MRIs, which are expensive and, for some schools, not readily available. MRIs can range from $1,000-$5,000.

However, when including those with subclinical myocarditis, the study revealed a higher percentage of athletes with myocarditis than other data sets—a 2.3% percent clip. That suggests that screening athletes who are showing heart-related symptoms, which most conferences are now doing, could mean missing myocarditis in some, Daniels says.

The long-term impacts of the myocarditis found in these athletes is unclear, but much of it cleared in follow-up MRIs. In fact, in subsequent testing, 100% of cardiac swelling resolved completely but testing showed some remaining scar tissue around the heart, Daniels says.

“What we don’t want is the message to be that we need to cardiac MRI every athlete,” says Johnathan Kim, chief of sports cardiology at Emory University. “It’s premature to suggest that. I do not think this changes the narrative as it relates to the way we should approach student-athletes trying to get back on the field after COVID-19.”

One of the issues with the study is the lack of “normative” cardiac MRI data, experts say. Basically, there aren't enough cardiac MRIs in healthy athletes to compare to those who have contracted COVID.

Another concern is the variances among the Big Ten universities. Two schools found myocarditis in 7% of their athletes while five schools found that just two of a combined 663 athletes had myocarditis, suggesting differences in how MRIs are being interpreted.

“The take home message is we have outcome data of other studies that shows the outcomes are quite good,” says Matt Martinez, the medical director of sports cardiology at Atlantic Health System in New Jersey who is the league cardiologist for Major League Soccer. “I’m concerned about the resources of conducting a cardiac MRI on every athlete. You’re talking about hundreds of thousands of dollars.”

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