Okay, thank you for the opportunity to be here, I really appreciate it. An honor to be here at AOSSM and to represent AMSSM. So getting right into it, we're going to talk about the cardiac effects of COVID in athletes or as you might find out, the relative lack thereof. I really have no disclosures. I am currently working for Kansas State in the Big 12, I'm shortly going to be working at CU in the Pac-12 and we'll see, maybe we'll be back in the Big 12 here very soon, we'll see what happens. So we're going to review how and why we made decisions that we made regarding COVID, discuss what we learned from the data and its impact on athletics and determine what, if any, issues there are moving forward. So this is, if you follow the New York Times, the timeline has been running for quite a while now. We started off with wild type virus, moved to alpha, then delta, and we're currently living in the time of Omicron, primarily BA5 sub-variant at this point. And so if you forgot, the World Health Organization formally labeled it COVID-19 back in February of 2020 and the world came to kind of a screeching halt, certainly the sports world did in March of 2020. You may not remember this, but Rudy Gobert, who was playing with Jazz at that time, pulled a bit of a bonehead move. So this was the very beginning of the pandemic. He was not feeling well. He was being interviewed and at the end, he wiped his hands all over these reporters' recording devices. And very shortly thereafter, tested positive for COVID and things kind of went from there. This was about the same time that several different groups started meeting routinely. This was one of the more prominent ones. There was a group of us in Power 5 that we could get on Thursday evenings and try to figure out what we were doing well and what we weren't doing well. And that led to some data a little bit later that I'll talk about. We also had groups from the MSSM as well as the NCAA that were meeting routinely. And when we started meeting, things looked not too bad. We were starting to crest in terms of cases at that point in time. Gosh, it looked like by the middle of June, we may be just fine with bringing everybody back and getting back to athletics. Little did we know. It was also about that time we started getting some data about hospitalization rates and specifically what those in the hospital were experiencing. One of the early studies was released online in March of 2020 out of Wuhan. Looked at about 400 patients. 19, almost 20% of those, showed some evidence of cardiac injury by evidence of elevated high sensitivity troponin. To some degree, we were a bit skeptical. Okay, is this data reliable? But shortly thereafter, we got some data of our own out of New York City, Mount Sinai, a larger cohort. About 36% of those admitted to the hospital had elevated troponins and 18.5% unfortunately ended up dying. That put us, it gave us many questions. Mainly, is this, is it right to take this cohort of patients that were in these studies that are really not the people we care for on a daily basis and restrict what we're going to do? And largely, we decided that we weren't. So most college athletics started coming back in June, July of 2020. Shortly thereafter, we got the initial cardiac MRI data. This was at the end of July. This was a study out of Germany looking at 100 patients, middle-aged, mostly mild to asymptomatic cases. And holy cow, 78% supposedly had cardiac involvement on cardiac MRI. 60% had evidence of mild cardiac inflammation. This certainly gave us many questions and we certainly didn't know what to believe or think at that point in time. It was also about that time that we got some local data. So this says September, but this data is actually out of Ohio State and Jim Borcher's group. And his, he was already letting us know in those meetings, hey guys, in our first cohort of 26, about 15% had evidence of mild carditis. This was out of West Virginia. Again, I know the team doc very well. He was raising alarms long before November. And we really started saying, how much can we rely on cardiac MRI? Is this the right test to be doing? Look at the numbers here. These are 26 athletes or 38 athletes. What's the inter-rater reliability from school to school? And so that said, when you start seeing stuff showing up in the news, like folks at the professional level getting mild carditis, you start having some deaths that are questionably related to COVID-19. It really puts a lot of people on pause. And as a sports medicine provider, a sports medicine physician, one of my primary roles in life is to try and prevent sudden cardiac arrest and death. And mild carditis is one of those leading causes of sudden cardiac arrest. So at that point, the Big Ten and Pac-12 decided that they wanted to put things on pause. The SEC and ACC were leaning towards moving ahead with athletics. It really came down to us and the Big 12 to decide what we were going to do as kind of the tiebreaker. We ultimately decided that there wasn't enough evidence to put things on pause, and we moved ahead. It was a little bit of an unpopular decision in the Big Ten and Pac-12 to put things on pause, and they quickly came around to a very robust testing strategy that allowed them to have a modified schedule in the fall of 2020. It's also this time that we finally got something off the ground that is actually doing very meaningful work in the world of sports cardiology specifically. For a long time, the folks you see here, especially those top three, John Dresner, Kim Harmon, and Aaron Baggish, have wanted to put together a cardiac registry for cardiac conditions that occur in athletes in general. For lack of momentum or funding, that hadn't happened, but now that we had COVID and we had way more questions than answers, they did receive funding from AMSSM and the American Heart Association to set up the Outcome Registry for Cardiac Conditions in Athletes, or ORCA. That was a good thing, because when we started trying to figure out what we were supposed to do with these student-athletes, it was largely based upon expert opinion. There are several iterations of this particular algorithm out there. It evolved with time. There were about six of us that started working on this, Aaron Baggish, John Dresner, Kim Harmon, Chad Asplen, Matt Martinez, and myself. Early on, a lot of it was, well, Dr. Baggish, what do you think we should do, or what do you think the workup should be, because we didn't have any data to support what the workup should be. Of course, we were erring on the side of caution at the time. The first and probably most important data that we had that came out of ORCA was our initial look into student-athletes that we had. This was put out in April of 2021. Little over 19,000 student-athletes, a fairly large swath of the United States, from most of those universities that you saw in that group, and 15.5% ended up getting COVID and a cardiac workup. About 80% of those got what we called the triple screen at the time, which was an EKG, echo, and a troponin. 317 got a cardiac MRI. 198 of those were because it was per protocol by that institution. 119 were because it was clinically indicated. Symptoms were typically mild to asymptomatic. Only about 13% presented with cardiopulmonary symptoms. This is what we found. In the protocol-driven cardiac MRI group, 1.5% were found to have what they thought to be definitive or probable contribution from COVID-19 to a cardiac condition. For those that were in the clinically-driven group, only 0.4% of those were found to have either definitive or probable evidence on cardiac MRI that there was a cardiac issue related to COVID-19. That was by the modified Lake Louise criteria. They also looked at, basically, what did we find? Well, 0.7% of those who were thought to have either definitive, probable, or possible were issues related to COVID-19. We were actually more likely to find, as it relates to all cardiac issues, congenital issues, problems that were already there for a long time. That first study showed us that, fortunately, COVID-19 did not seem to be playing a huge role in cardiac issues in student athletes. Five of those from that original 19,000 group required hospitalization for non-cardiac-related issues. Only one had a cardiac arrest that was unrelated to COVID. Subsequently, we determined that. You had about a 0.4% to 1.5% chance of definitive or probable cardiac involvement, depending on how you set up your MRI protocol. You're about seven times more likely to have cardiac involvement on cardiac MRI if it was for a clinically-indicated reason, as opposed to protocol. You're about three times more likely that we would find a congenital cardiac issue, as opposed to a cardiac issue related to COVID-19. Fortunately, this was corroborated in several other large studies. ORC has also subsequently put out some additional data. This looked at persistent or exertional symptoms. So in that 3,600 or so student athletes, only 44 had symptoms beyond three weeks. And in fact, out of that group, 63% of them, their symptoms were a loss of sense of taste and smell. So really, only 0.6 had symptoms beyond three weeks that were not loss of sense of taste or smell. Only two had symptoms longer than 12 weeks. That's the cutoff for post-acute COVID syndrome. And where exertional symptoms were reported, only 137 student athletes had cardiopulmonary symptoms, and only five had cardiac involvement on cardiac MRI. All of those, interestingly, had chest pain at presentation. Those who had non-chest pain exertional symptoms were not found to have abnormalities on cardiac MRI. And then the most recent study that has been produced by ORCA is a one-year follow-up. There had been no adverse cardiac outcomes in those initial folks that had abnormalities on cardiac MRI. There were a couple of cardiac outcomes in the group that did not have a cardiac MRI done. One was a resuscitated sudden cardiac arrest not related to COVID, and one was a round of AFib that they thought was possibly related to COVID. Unfortunately, any death is obviously a tragedy. The National Center for Catastrophic Sport Injury Research looked from March of 2020 to July of 2021, and only found four deaths that they thought were related in student athletes to COVID-related issues. Again, any death is tragic, but fortunately, this was far better than we thought we might be dealing with back in June of 2020. So my take-home points, fortunately, COVID cardiac involvement is low in athletes. Evidence supports a tiered symptom-based cardiac testing strategy. Asymptomatic or mild infections do not require initial cardiac testing. Cardiovascular abnormalities are no more common in seropositive versus seronegative healthy individuals. Cardiac MRI should really be reserved for athletes with abnormal cardiac testing or cardiopulmonary symptoms during exercise.

COVID-19

athletes

cardiac involvement

sports medicine

registry data