Let’s get to the verdict first. Is the threat of heart damage a reason to close down college or high school football?

“In my opinion, the concern of myocarditis, or possible myocarditis from COVID-19, is not a reason to cancel sports,” Dr. Jason Johnson said.

Johnson is associate chief of pediatric cardiology — and director of the cardiac MRI — at Le Bonheur Children’s Hospital. He may even know more about this than a Twitter expert.

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So now that the fear of myocarditis seems to be driving decisions to postpone the Big Ten and Pac-12 football seasons — and now that more and more regular folks are wondering if they or their children are at risk for heart damage — I thought I’d talk to a local heart expert about what college administrators and parents should do.

To be clear: Johnson offered no opinion about the epidemiological impact of playing sports during a pandemic. His focus is on the heart. And while he says that careful monitoring and testing is critical, he does not think myocarditis is a reason to shut everything down. 

Q: What is myocarditis, anyway?

A: Myocarditis, simply put, is inflammation of the heart muscle caused by many different things, but typically viruses.

Q: Any virus can cause it? Not just COVID-19?

A: Yes. The flu virus, rhinoviruses, parvoviruses. The different types of viruses that typically cause myocarditis have actually changed over the years, but any virus has been linked to causing this inflammation of the heart.

Q: You see it as a regular part of your practice?

A: At Le Bonheur, on average, we diagnose this in children about 20-30 times a year.

Q: Before COVID-19?

A: Yes. Most of the time, we may not even know what virus led to it. Typically, they’ll have a story of an infectious syndrome, cough, fever, runny nose, for two or three weeks prior to the presentation. Then they start having cardiovascular symptoms like chest pain or palpitations and that’s how they come to our attention.

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Q: Once you diagnose it, do the patients do OK?

A: The vast majority of the patients recover and recover completely. It is extremely rare to have significant cardiovascular outcomes from myocarditis but it can happen. So sudden death and decreased heart function needing multiple medications can happen, but it’s very rare. It’s really not that common. Most patients who get this will recover with normal heart function over a period of time.

Q: If myocarditis was here before COVID-19, why is it getting so much attention now?

A: COVID-19 is the most studied virus in the history of viruses. We’re just asking the questions a lot more. This virus is also probably a little bit more predisposed to causing myocarditis because the way it enters into cells, there is a specific receptor on the heart muscle cell, that allows it to enter the heart muscle a little bit more than maybe the other viruses. It’s a little bit easier for it to enter the heart.

Q: So if someone gets COVID-19, or someone has a teenage athlete who gets COVID-19, what is the proper course? Should every COVID-19 patient get a cardiac workup?

A: We’ve been getting a lot of questions from general pediatricians and nurse practitioners because it’s so prominent in the reports that people wonder, “Well, should I evaluate every patient for possible myocarditis that gets COVID-19?”

And right now, the answer is probably “No.” As long as you are asymptomatic, we really don’t recommend further testing. If you are an athlete, then it depends on the symptoms you had. If you had severe symptoms, and you required hospitalization, then we will definitely do some screening tests to make sure your heart function is normal and you didn’t have any lasting effects from that syndrome.

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If you had more moderate symptoms, if you felt terrible but you were able to stay out of the hospital, then it would depend on your age and what activity you’re going back to. If you’re just going back to physical education classes and not really competition-level athletics, then we would probably just recommend an electrocardiogram and if that was normal, then we wouldn’t recommend any further testing.

If you’re a higher-level athlete, you know, cross-country, or participating in basketball or football or any of those higher competitive sports, and you had some cardiovascular symptoms, then we would recommend more screening tests with some blood work and an echocardiogram.

Q: If my kid was 17 years old, played football, felt terrible for two weeks but didn’t go to the hospital, what would you suggest?

A: What we would recommend at this time is an electrocardiogram and if that electrocardiogram was normal, then we would probably do a little bit more. We would probably do some blood tests looking for myocardial damage and do an echocardiogram and, if either one of those was abnormal, then we would do a specific test called the cardiac MRI.

Q: A cardiac MRI would reveal any damage?

A: The cardiac MRI is kind of the gold standard on how to diagnose myocarditis.

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Q: Obviously, this issue is coming up because there is a perception that concern about myocarditis caused the Big Ten and the Pac-12 to shut down. What is your level of concern about the cardiovascular impact of COVID-19? Is it a reason to shut down the whole enterprise?

A: People are obviously answering this question differently. In my opinion, the concern of myocarditis, or possible myocarditis from COVID-19, is not a reason to cancel sports. As long as people understand those potential risks — and understand there is a possibility of that happening in any person regardless of whether they participate in sports — then you can proceed as you see fit.

But what we would recommend in these college-level athletes is a lot more detailed evaluation because they are going to be at the top echelon of their fields and they’re going to be really exerting themselves. So we want to make sure they are protected before they return to the field.

So what we would do, even in college-level asymptomatic athletes, we would make sure that we had done those screening tests with the electrocardiogram, the echocardiogram and that blood test. And if any of those are abnormal, then we would do the cardiac MRI.

Q: I guess the goal is to identify any damage before the athlete starts to practice or compete again? Because if there any damage, the athlete could sit out and the heart would recover in time?

A: That’s the whole reason to evaluate them, to make sure they aren’t putting themselves at risk. We wait at the appropriate time to quarantine them, 14 days, then after that appropriate period of time we get our test results. And if the screening tests are normal, then they can go back to participating as long as they feel fine.

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If the screening tests are abnormal, then we can get them the more specific test, the cardiac MRI. And if that shows evidence of scarring, then we would put the athlete out for three to six months give or take, and then we would need to administer another MRI to see if it has improved.

Q: Is this what the University of Memphis and the American Athletic Conference are doing?

A: One of my colleagues, Dr. Ranjit Philip, is the cardiologist for the University of Memphis. They recently had a call from the AAC and this whole protocol was actually what was discussed.

And the first question they asked all the cardiologists was the question you asked me: “Is the concern of myocarditis a reason to cancel the season?” And all the cardiologists said, “No.”

And then they said: “OK, if we all say no, then how do we proceed?” And this is what the AAC decided is reasonable.

So what the Big 12 does or what the SEC does may be different than what the AAC does. But overall, the theme is that we’re trying to screen these athletes in an appropriate manner to make sure they are not at risk for damage to their heart while they are participating in high-profile athletics.

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Q: There was an academic paper that triggered a lot of this discussion in the media. Can you tell me about that?

A: It’s always an issue when a cardiac MRI paper is being discussed in People magazine. There was a paper out of Germany where there were 100 patients that had previously had COVID-19 and they did cardiac MRIs on all of them. They looked at all the parameters we normally look at. And that paper reported that 78 percent of those patients had some abnormality in the cardiac MRI.

So, of course, what gets picked up by People magazine is that 80 percent of people after a COVID -19 infection have heart abnormalities. So that made a lot of people uncomfortable. If you look actually at how we use it, clinically, only 22 of those patients would have been diagnosed with myocarditis and only 3 percent had decreased heart function.

So most of the clinical cardiologists would say: “Yeah, well, maybe they had some technical abnormalities. But it wasn’t as dramatic as it was reported.”

Q: Last question. I’m no Olympian, but I run. If I get COVID-19 and feel miserable for two weeks but don’t go to the hospital, should I worry that next time I go on a long run I’ll drop dead?

A: The point of this is discussing it with your primary care physician. They can do a screening electrocardiogram. If there’s any abnormalities on that, they would do some more testing. But if that screening electrocardiogram is normal, and you really had a mild case, then you’re a very low likelihood to have any major problems.