Cardiac MRI Imaging for Athletes Recovering From COVID-19?

Watching competitive sports is one of my entertainment diversions from the realities of a COVID-19 pandemic, economic hardships created by the pandemic and of course divisive political discourse in our nation. When I watch a sporting event, and I am rooting for one team, I have my protective emotional shield for sudden medical tragedy turned off. That was the case as I watched the University of Florida men’s basketball team play their rivals, Florida State University, earlier this year.

A close friend’s grandson was one of the managerial courtside support staff, so we watch the games as much to see him run out on the court during breaks in the action as we do the game.  It was early in the game, after the player voted most likely to be the conference MVP shot a ball that came nowhere close to the basket and the teams were leaving a timeout, when this star just dropped to the floor face first as if he had been shot.  It was shocking to me in this unexpected location to see a life-threatening tragedy evolve in a young fit athletic man entering the prime of his life. From the looks on the players and coaches and then medical staff it was apparent this was a catastrophe unfolding. CPR was begun courtside and rapidly he was moved by stretcher to an ambulance and a critical care unit. 

The team and school and physicians protected the players privacy closely. Interviews with friends indicated he was placed into a hypothermic medically induced coma to save his brain and internal organs.  It was not until several days later that it became apparent that this player would survive.

Three months earlier he had caught and survived the coronavirus, COVID-19.  He went through a complete physical before he was cleared to train and play again. It is unclear what that exam consisted of beyond an EKG, Stress test, echocardiogram and heart muscle enzymes but the medical staff at Shands Hospital in Gainesville, Florida treats many athletes and is as elite as the athletes that grace the school’s playing fields. The unofficial diagnosis is that he had post COVID-19 inflammation of the heart muscle known as myocarditis. No official diagnosis has been presented to the public due to privacy considerations and laws.

A research paper in the European cardiology literature looked at 100 plus COVID-19 patients with minimal symptoms not requiring hospitalization for the disease. A cardiac evaluation including an MRI of the heart revealed unexpected inflammation of the heart muscle in over 50%. These patients were older in average age and were not elite athletes.  The question then arises “Should all individuals recovering from COVID-19 undergo a cardiac MRI and see a cardiologist prior to resuming strenuous exercise workouts?”.  

The Big Ten Athletic Conference decided that all their athletes with COVID-19 would receive an MRI as part of a battery of tests prior to receiving permission to resume training and play. This was influenced by several professional athletes taking a sabbatical post COVID-19 due to the onset of myocarditis.

The University of Wisconsin Departments of Medicine and Radiology published a study in JAMA Cardiology presenting the results of Cardiac MRI’s in 182 athletes recovering from COVID-19 at the three-week mark. Only two student athletes had MRI evidence of myocarditis.  The cost of a cardiac MRI in the United States is listed from $1500 -$7500.  I have no idea if insurance companies will pay for a cardiac MRI or not. 

The conclusion of the study authors, from this small study, is that MRI screening for myocarditis is of questionable value.    I beg to differ.   Had these elite athletes been allowed to resume training and suffered a similar fate to the University of Florida basketball player the cost of the test, which provides no X irradiation exposure, seems inexpensive. If I had a teenage child recovering from COVID-19 and hoping to strenuously work out or try out for a sports team at the local high school I would certainly want that test performed as part of a cardiology evaluation before I gave my blessing to participate. 

More studies will be done on the long-term effects of COVID-19 on minimally symptomatic or asymptomatic survivors. I stress caution in resuming aggressive physical activity until our data base is more complete.

Do Cipro and Levaquin Cause Abdominal Aortic Aneurysms?

Melina Kibbe, MD, of the University of North Carolina Medical Center at Chapel Hill published an article in JAMA Surgery reviewing any possible relationship between taking fluoroquinolones antibiotics such as Cipro or Levaquin and the subsequent development of an abdominal aortic aneurysm.  An aneurysm is a weakening in the wall of a blood vessel that balloons out like the defect on a damaged tire or basketball and has the potential to rupture causing exsanguination and sudden death. Dr Kibbe is also the editor of JAMA Surgery.

The study looked at health insurance company data on antibiotics and aneurysm diagnosis and repair.  They found that 7.5 aneurysms formed per 10,000 fluoroquinolone prescriptions filled at 90 days. This was significantly higher than the 4.6. per 10,000 aneurysms formed after patients took non-fluroquinolone antibiotics.  Patients filling fluroquinolone prescriptions were more likely to undergo repair of aneurysms than those who took other types.

The study used data from IBM MarketScan health insurance claims from 2005 to 2017 in adults aged 18-64.  The study included data on 27,827,254 individuals. The data did not include smoking or hypertensive history or family history of vascular disease. The authors were hoping the FDA would require a warning or caution to high-risk individuals for developing an aneurysm.

We already see an increase in ruptured tendons in patients taking fluroquinolones – especially women who have taken corticosteroids. They are also associated with C difficile colitis, nerve damage, emotional health issues and low blood sugar events. 

Despite these known draw backs to these medications, patients continually demand to have Cipro or Levaquin on hand in case they develop a urine infection or upper respiratory infection or are travelling and concerned about traveler’s diarrhea. 

More research is needed to determine the exact risk of prescribing these medications. Should we be doing scans on patients with hypertension and or smoking history who frequently use these drugs to screen for an abdominal aortic aneurysm?  This is a question that will be addressed by a study soon.  While the research is in process, we need to make sure that our prescribing of these antibiotics is the safest choice for our patients.

The COVID-19 Vaccine Is Becoming More Available. Exercise Patience.

COVID-19 vaccine preparations are arriving in South Florida with several hospital systems opening appointments for men and women 65 and older to receive their first injection. Some will receive the Pfizer product, others the Moderna product. If you wish to travel to Dade County go to https://jacksonhealth.org/keeping-you-safe/  and sign up for the vaccine. They are taking appointments.  West Boca Medical Center and Boca Regional Hospital have opened appointments for non-employed medical staff members and their office staffs to receive vaccine with the hint that the week of January 11, 2021 they will start vaccinating community members.  

There is a sense of urgency and panic in the community about not having access to the vaccines. That is unnecessary and raising the stress level inappropriately.

After you receive your first vaccine dose you will still need to avoid crowds, social distance, wear masks and practice impeccable hand washing hygiene because you will not be immune. Twenty-one to 28 days later you will receive your booster shot and it will take about two weeks before we can detect antibodies to COVID-19 if you develop immunity.  You will have peace of mind, but won’t know if the vaccine prevents individuals from catching COVID-19 when exposed completely?  Will they get COVID-19  and have a very mild case because of the vaccine prevention?  Will these people be contagious to others? We do not know the answers to these questions yet.

If you get the vaccine, develop immunity and are exposed to someone with COVID-19, will you possibly transmit the virus to others without you yourself becoming ill?  No one knows the answer to that question yet either.  If everything goes perfectly well, and you develop a protective shield of immunity like a comic book superhero shield or cape, how long will that last?  Nobody knows that answer either.

The point is the vaccine is coming.  Once vaccinated we will still have to behave the same as before until the answers to these questions are known!  Please be patient.

COVID-19 Vaccine Availability

Update January 4, 2021

Last week the Florida Department of Health discussed providing the Moderna vaccine to our office for staff members who wished to receive the vaccine. Our office manager, Judi Stanich, requested enough vaccine to cover the entire practice. We were told we would have a confirmation this morning.

This morning we learned the vaccine isn’t available yet. The vaccine comes in vials of 10 shots. The vials are kept frozen and can remain active in that state or in a refrigerator for 30 days. Once a vaccine vial is opened the entire vial must be used in under six hours or it degrades.

Moderna and the Florida Department of Health require patients to complete legal release forms for the vaccine. They must then be registered into the Florida Shots data bank and a national data bank. That is one of the reasons patients are asked to bring their driver’s license with them.

If you have had a severe allergic reaction to any medication the Pfizer and Moderna mRNA vaccines may not be best for you. If you have ever had to use an Epi Pen or have been treated for anaphylaxis these shots are not for you. The Astra Zeneca Oxford vaccine and the Johnson and Johnson vaccine are thought to be more suitable for those individuals

After receiving your shot, you will need to be observed by medical staff for 15 minutes to look for adverse reactions. You will be given an instructional sheet on how to register with V-SAFE which is a CDC vaccine monitoring app. Every day, at about 2:00 p.m., you will receive a text message with questions about how you feel related to the vaccine.

Medical malpractice insurance companies have not yet formally announced whether physician insurance policies will cover administration of this vaccine in their offices because none have been FDA approved. The Pfizer and Moderna vaccines have received FDA Emergency Utilization Authorization (EUA) which is not the same as approval.

Currently the only avenue to obtaining the vaccine in Palm Beach County is to try and get through on the 561.625.5180 phone number or leave your demographics on an email at CHD50Feedback@Flhealth.gov. Baptist Health System is planning on opening reservations for seniors 65 years of age and older the week of January 11 working with Boca Regional Hospital, Bethesda Hospital and the FAU Schools of Medicine, Nursing and their EMT program. They have not announced how to make a reservation or if they will be using the data from the Palm Beach County Department of Health through the phone number and email address provided above.

I suspect that by the middle of February there will be plenty of vaccine available locally including the Astra Zeneca Oxford product and the Johnson and Johnson products. In the meantime, remain patient and continue to avoid crowds and continue to social distance, wear suitable face masks and keep up the hand hygiene. Please remember that after you complete your vaccinations (two shots for the Pfizer and Moderna Products) we will not know how much immunity the shots will provide and for how long.

We additionally do not know if successfully vaccinated individuals are completely immune or partially immune if they are exposed to the virus. Furthermore, we don’t yet know if you are vaccinated whether you can carry the virus and transmit it to someone else even if you don’t have any symptoms.

Getting the vaccine will not be a reason to resume activities at crowded gyms, crowded bars or go on that cruise ship just yet. The hope is that by the summer 2021 we will have the answers to the many unknowns.