I Was Wrong Regarding Athletes Post COVID-19 & Inflammatory Heart Disease

In a January 2021 blog post, I criticized college athletic departments for allowing their athletes who were infected with SARS-CoV-2  to resume training and competing in their sport without taking a cardiac MRI scan first. This was based on an article early in the pandemic from Italy citing the large number of inflammatory heart issues seen in 100 relatively mildly symptomatic COVID patients.  There was unexpected heart inflammation found in over 50% of these older nonathletic individuals.

The Big Ten Intercollegiate Athletic Conference published an article from the University of Wisconsin Department of Athletics a few months later. All their athletes recovering from COVID (182) received a cardiac MRI at the three-week mark and only two students had MRI evidence of myocarditis.  Based on this small study, other institutions decided that a history session, physical exam, electrocardiogram, echocardiogram and laboratory measurement of the athletes’ cardiac muscle troponin levels would be sufficient. Athletes with abnormalities on any of those tests were referred for a cardiac MRI which could cost $1500- $7500 per study.  I was extremely critical of that decision citing the large amount of income these athletes generated for their university and the potential cost in terms of long-term medical care, potential lawsuits and negative publicity from an athlete becoming seriously ill.  

Like most information regarding this pandemic over time, we learn more about the disease and how to diagnose and treat it. The more familiar we become with Sars2 coronavirus the more previous beliefs change.

This week researchers reported in the Journal of the American Medical Association Cardiology that very few elite athletes recovering from COVID-19 develop myocarditis.  They pooled medical data from May 2020 until October 2020 from Major League Baseball, Major League Soccer, the National Hockey League, the National Football League and the Men’s and Women’s National Basketball Association.

789 professional athletes tested positive for SARS-CoV-2 and entered the return to play protocol (RTP). Athletes who tested positive had a cardiac screening 19 days after their positive test without cardiac MRI imaging. From this group, only 30 athletes had abnormal results and were sent for additional screening. Cardiac MRI was performed on 27 of the 30 and inflammatory heart disease was found in 5 of them. This represents 0.6% of the original screened group. Three of the athletes had confirmed myocarditis and two had pericarditis. These athletes were held out of training and competition. The other 25 returned to training and competition.  None of those athletes who returned to competition had a cardiac illness related event as of December 2020.

In my blog I  tried to provide the ultimate safety evaluation and recommendation for athletes. My patients are older – not elite and anxious to resume their grueling workouts with their local personal trainers.  Given the knowledge base at the time I would make the same choice leaning towards safety, but the data proved me wrong. 

As we learn more about this disease previously held beliefs will be disproved. We have learned that hydroxychloroquine does not work in the treatment of the disease even though initial expectations were that it would. We learned that the virus does not last exceptionally long on surfaces but in the beginning a published article about the cleansing process on the cruise ship Yokahama Princess showed the virus survived 17 days on the ship’s surfaces. We learned that convalescent plasma does not save lives in severely ill patients. This is what happens in the field of science. The CDC and Dr Fauci do not flip flop and are not wrong. As information becomes available, they review the data and try and explain it to the rest of us. As the data changes over time, and the picture changes over time, they adjust their recommendations to be consistent with the facts. They tend to err on the side of caution and safety, as will I, as we move through this tragic pandemic.

Doctors of Pharmacy and Their Role in the Health Care Team

My patient, a mental health professional, was sent for an MRI of her hips and back by her orthopedic surgeon. He was in surgery when she called him for an antianxiety medication to help her get through her claustrophobia in the MRI machine.

She waited seven hours for a response and when a repeat phone call resulted in no response she called me. I asked her if she was driving herself to or from the procedure and she answered no that her husband was taking her. I phoned in a small supply of a longer acting antianxiety medication called lorazepam 0.5 mg one tablet 30 minutes prior to the procedure. It was called in at 4:00 p.m. after we first accessed the in-state narcotic prescribing line Eforsce to make sure our patient was not pill or doctor shopping.

I received a phone call at 9:00 p.m. that evening from the patient who was at the pharmacy saying they didn’t have lorazepam in stock. It was unclear to me why, if they did not have the medication in stock, no one was responsible enough to call me and request an alternative prescription? I called the pharmacy in response to the patient calling me and ordered another product. However, they did not respond to my question “Why didn’t you call me if the medicine I ordered was not available?”

This week a 63 year old woman with three days of painful urination came to my office. Her urine suggested an infection. I called her pharmacy to phone in a prescription for ampicillin until her culture and sensitivity results were known. The pharmacist said she was too busy to take the call and asked me to leave a message. I waited for the beep and left the message. Thirty six hours later I received a fax to my office telling me that they were out of ampicillin and did not offer an alternative. I immediately called the pharmacy, furious at the delay and prescribed an alternative medication. Once again, if they did not have the ampicillin then why did it take them 36 hours to inform the patient or me? Why was this done by facsimile and not a phone call? The potential for complications of an untreated gram negative urine infection is frightening and life threatening. This should never occur. Then again why isn’t a common inexpensive antibiotic available in South Florida?

This is not very different than the blood pressure medicine Valsartan recall due to production induced impurities. When the recall was announced, I searched my computer and contacted my patients taking this medication to discuss options. For those demented and cognitively impaired patients I first called the pharmacy to ask if their supply was part of the recall. Much to my surprise much of it was under recall but the pharmacy had no intention and felt no professional responsibility to inform the customers who they had sold the tainted product to.

Pharmacists continually stress their professionalism as part of the health care team. These are three recent local examples of their need for improvement.

Fish Oils in Osteoarthritis – Low Dose vs. High Dose

Using the common sense approach that if a little bit is good then more is better in the treatment of “rheumatism” Catherine Hill, M.D., of the University of Adelaide in Australia and colleagues looked at the effect of taking low dose fish oil supplements versus high dose fish oil supplements. When one looks at the adult population of Australia, one third of them take fish oil supplements and had within a month of this study. The typical dose is one ml of fish oil per day. Experts say the dose for anti-inflammatory effect for arthritis is considerably higher at 2.7 gram or 10 ml per day. Dr Hill’s theory was that high dose fish oil for symptomatic and structural outcomes in people with knee osteoarthritis was better.

She enrolled 202 symptomatic patients in a double blind study. High dose group patients received 4.5 g EPA/HPA per day. The low dose group were given a blended of fish oil containing 0.45 g EPA /DHA per day in combination with Sunola oil. Both supplements were flavored with citrus oil.

All patients received a baseline MRI of the knee at inception of the study and at two years. The patients mean age was 61 years and body mass index was 29kg/meter squared. Both groups showed x-ray evidence of arthritis in the knee at inception and both groups were allowed to take non-steroidal anti-inflammatory medications and acetaminophen for arthritic pain during the course of the study.

At two years there was no difference in the MRI findings or cartilage volume loss between the high dose and low dose groups. Each group took similar amounts of NSAIDs and acetaminophen for pain on a regular basis. The high dose had no benefit over the low dose.

The researchers concluded that there was no benefit in their study to high dose versus low dose fish oil supplementation for arthritis. They reasoned that since patients in the study were permitted to take additional fish oils on their own during the study this may have altered the findings. The researchers additionally had little control over how much fish the participants ate.

In reviewing the data it seems to indicate that fish oil played a minor role in slowing down arthritis in the knee joint. Low dosage had as good of an effect as high dosage but the studies lack of a true control group who did not take fish oil at all made the conclusions hard to accept.

I will suggest to my patients that they continue to eat two fleshy fish meals per week to get their fish oils for arthritis and cardiovascular protection, rather than purchasing and taking low dose or high dose fish oil supplements.