Falling through the cracks

Those screening guidelines, published by a group of leading sports cardiologists in October, call for cardiac tests only for athletes with moderate or severe COVID-19 symptoms. Athletes with asymptomatic cases or those with mild symptoms that have gone away can return to play without the additional testing. The National Federation of State High School Associations and the American Medical Society for Sports Medicine have put out similar guidelines for high school athletes.

But that approach would not flag players such as Demi Washington.

Washington, a 19-year old sophomore on Vanderbilt’s women’s basketball team, had a rather mild case of COVID-19. She had shared a meal with two teammates, one of whom later turned out to be infected. Seven days into a two-week quarantine in a hotel off campus, Washington also tested positive, and had to isolate with a stuffy nose for an additional 10 days. She waited for her symptoms to get worse, but they never did.

“It felt like allergies,” she said.

But when her symptoms cleared and she returned to practice, the university required her to undergo several tests to ensure the virus had not affected her heart. The initial tests raised no concerns. An MRI, though, showed acute myocarditis.

Her season was over, but, more importantly, Washington, an athlete in prime physical condition, faced the possibility of losing her life. She learned about Hank Gathers, a 23-year-old Loyola Marymount basketball star who collapsed during a game in 1990 and died within hours. His autopsy confirmed an enlarged heart and myocarditis.

“That really put me on the edge of my seat,” Washington said. “I was like, ‘OK, I have to take this seriously, because I don’t want to end up like that.’”

For months, she had to keep her heart rate under 110 beats per minute. Before, she ran 5 miles a day. With the myocarditis diagnosis, she had to wear a heart monitor, and even a brisk walk could push her above that threshold.

“One time I was walking to the gym and I might have been walking a little fast,” Washington recalled. “My chest got really, really tight.”

By mid-January, however, another MRI showed the inflammation had cleared, and she has since resumed working out.

“I’m so grateful that Vanderbilt does the MRI, because without it, there’s no telling what could have happened,” she said.

She wondered how many other athletes have been playing with myocarditis and didn’t know it.

Cases like Washington’s raise questions about how aggressively to screen. Her condition was found only because Vanderbilt took a much more conservative approach than that recommended by current guidelines: It screened all athletes with cardiac MRIs after they had COVID-19, regardless of the severity of their symptoms or their initial cardiac tests.

Of the 59 athletes screened post-COVID-19, the university found two with signs of myocarditis. That’s just over 3%.

“Is the current rate of myocarditis that we’re seeing high enough to warrant ongoing cardiovascular screening?” asked Dr. Daniel Clark, a Vanderbilt sports cardiologist and lead author of an analysis of the school’s screening efforts. “Five percent is too much to ignore, in my opinion, but what is our societal threshold for not screening highly competitive athletes for myocarditis?”

Even though myocarditis is rare, studies have found that non-COVID-related myocarditis causes up to 9% of sudden cardiac deaths among athletes, said Dr. Jonathan Drezner, director of the University of Washington Medicine Center for Sports Cardiology, who advises the NCAA on cardiac issues. Thus COVID-19 adds a new risk. The NCAA alone reports more than 480,000 athletes. To provide a sense of scale: If all of them got CCOVID-19 and even 1% were at risk of heart problems, that’s 4,800 athletes.

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