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COVID-19 viral infection and myocarditis in athletes: the need for caution in interpreting cardiac magnetic resonance findings
  1. Alessandro Zorzi,
  2. Alberto Cipriani,
  3. Domenico Corrado
  1. Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Veneto, Italy
  1. Correspondence to Professor Domenico Corrado, Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Veneto, Italy; domenico.corrado{at}

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Common viral infections may cause a number of acute diseases that involve organ systems outside the respiratory tract, including inflammation of the heart muscle (myocarditis).1 Diagnosis of myocarditis by cardiac magnetic resonance (CMR) traditionally relies on myocardial tissue characterisation abnormalities such as increased signal intensity on T2-weighted sequences (oedema), early gadolinium enhancement (hyperaemia) and late gadolinium enhancement (LGE) (necrosis and/or fibrosis).1 Myocardial T1 and T2 mapping are recent techniques that allow a more accurate characterisation of myocardial tissue changes induced by inflammation.2 According to the 2018 revised ‘Lake Louise’ criteria, diagnosis of myocarditis is fulfilled in the presence of relevant symptoms when at least one of the T1-based criteria plus at least one of the T2-based criteria are met.3

At the beginning of the COVID-19 pandemic, there was concern that heart muscle could be more frequently involved by SARS-CoV-2 infection than by other respiratory viruses. In athletes who recovered from COVID-19, a small study on 26 subjects reported 4 (15%) fulfilling Lake Louise criteria for myocarditis and 8 (31%) with isolated LGE,4 while subsequent investigations with larger cohorts of athletes showed a much lower prevalence of myocardial involvement (online supplemental table).

Supplemental material


In a recent study in the British Journal of Sports Medicine, Szabó et al 5 provided a new piece of evidence on the true incidence of myocardial tissue abnormalities at CMR in athletes who tested positive for SARS-CoV-2. The study had many methodological strengths: a large study population; a comprehensive and updated CMR tissue characterisation protocol, including T1 and T2 mapping; the availability of a subset of athletes with both pre-COVID and post-COVID CMR studies; and the inclusion of a cohort of …

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  • Contributors All authors contribute to manuscript drafting and revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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