key: cord-0736996-loso8a96
authors: Ng, Ming-Yen; Ferreira, Vanessa M.; Leung, Siu Ting; Yin Lee, Jonan Chun; Ho-Tung Fong, Ambrose; To Liu, Raymond Wai; Man Chan, Johnny Wai; Alan Wu, Ka Lun; Lung, Kwok-Cheung; Crean, Andrew M.; Fan-Ngai Hung, Ivan; SIU, Chung-Wah
title: Recovered COVID-19 Patients Show Ongoing Subclinical Myocarditis as Revealed by Cardiac Magnetic Resonance Imaging
date: 2020-08-28
journal: JACC Cardiovasc Imaging
DOI: 10.1016/j.jcmg.2020.08.012
sha: 106164270bb917017137032f97d515496b669bdf
doc_id: 736996
cord_uid: loso8a96

nan

The cardiovascular complications of coronavirus disease 2019 (COVID-19) are still being established 1 . Expert guidelines recommend the use of cardiac imaging in the management of COVID-19 patients 2 , and cardiovascular magnetic resonance (CMR) has demonstrated utility in the non-invasive detection of myocardial inflammation 3 . We present a case series of 16 recovered COVID-19 patients who underwent CMR to assess for evidence of myocardial involvement or ongoing myocarditis.

Ethics approval was obtained from the Hong Kong West Cluster (UW20-359) Institutional Review Board for this retrospective study. Inclusion criteria were COVID-19 patients admitted as inpatients to Queen Mary Hospital, referred for outpatient CMR postrecovery for raised troponin or electrocardiogram (ECG) changes during the acute illness.

Exclusion criteria were poor quality CMR preventing assessment of ventricular function and late gadolinium enhancement (LGE). COVID-19 was diagnosed based on reverse transcription polymerase chain reaction (RT-PCR) tests of nasopharyngeal and throat swabs. Louise criteria for myocardial inflammation 3 -one had chest discomfort with mildly elevated CRP; one was asymptomatic but with elevated troponin (figure 1); one was asymptomatic with no blood biomarkers of inflammation. The fourth patient with LGE had a known history of NSTEMI with circumflex artery stenting, showing a lateral wall infarct but no myocarditic changes. In the rest (all 12 without LGE), 4 patients had elevated T1 only, 1 had elevated T2 only, and 1 had both elevated T1 and T2. Of these, 4/6 had blood biomarkers of inflammation (high WBC, CRP or Troponin), and 3/6 had ongoing symptoms (1 cough, 1 cough/ SOB, 1 SOB/chest discomfort). The remaining 6 had normal T1, T2 and no LGE: 5/6 were asymptomatic, of which 2/5 still had elevated troponin, 1/5 had elevated CRP, and 2/5 had normal blood tests . None had pericardial thickening or effusion.

Our study demonstrates subclinical ongoing or resolving myocardial inflammation in recovered COVID-19 patients, as revealed by CMR. A Wuhan study showed that 58% of recovered COVID-19 patients had abnormal CMR findings, but all had cardiac symptoms 5 .

In contrast, our study extends that, although 69% (11/16) of recovered COVID-19 patients were asymptomatic, a majority (56%, 9/16) showed abnormal CMR findings (high T1 and/or T2, +/-non-ischemic LGE), 67% (6/9) of whom had accompanying blood biomarkers of ongoing inflammation, even if asymptomatic (3/6). In asymptomatic patients, 45% (5/11) had abnormal CMR findings; 27% (3/11) of asymptomatic patients also had corroborating serological evidence of inflammation. In symptomatic patients, 80% (4/5) had abnormal 

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World Health Organization. Clinical Management of COVID-19

patients identified by magnetic resonance imaging