Mayo Clinic cardiologist Dr. Michael Ackerman analyzes the Myocarditis issue

The latest issue to arise in the ‘play or not to play’ CFB saga of 2020 is the issue of Myocarditis caused by COVID-19. To learn more about Myocarditis and its impact on coronavirus patients, we talked with Dr. Michael Ackerman, a cardiologist from the Mayo Clinic.

Full transcript from our interview with Dr. Michael Ackerman
 

Gabe Bock: Now, we're about five months into an outbreak becoming a full-blown pandemic in our country. How much have we learned about the disease, Dr. Ackerman, and how much do we continue to learn as the days go by, and especially, in figuring out how to properly treat it?

Dr. Michael Ackerman: “Great question, Gabe. Obviously, we've learned a ton from knowing nothing in December, January to knowing an awful lot. So, there are a lot of knowns, a lot of unknowns, and we're in this phase of coexisting with the virus and with COVID-19, the disease, until and unless we get an effective vaccine. And so, everybody's trying to figure out what does this coexistence with SARS-CoV-2 look like? What can we do? What can we not do? What's safe? What's not safe? And so, it's always difficult when we're in this sort of non-zero risk situation that we find ourselves in.”

GB: I want to approach this segment today and your appearance from a college football angle, and we'll start with this. What do you make of the college football news this week? But from your standpoint, from a medical, and a public health standpoint, with two Power 5 leagues deciding it wasn't safe to play fall sports, and then three other Power 5 leagues deciding, at least for now, it's safe enough to continue to progress toward the idea of playing.

Dr. Ackerman: “Yeah, it's been interesting. I would like to say, "I'm a huge college football fan," but full disclosure, I've only been to two Division I football games in my entire life. So, I really don't care from that standpoint. The reason I threw down the red flag the other day, and asked for a time out, and asked for the officials to look under the hood, and look at the evidence is I was starting to hear that being put forward as a primary driving reason was the spooky, scary playing-with-fire COVID-19 myocarditis deal.

Dr. Ackerman: “And that's where I wanted to say "time out" because if the evidence that was being put forward as the primary reason for a shutdown of sports was that, that I didn't think that was appropriate. And the second thing, the reason I did that was my own patients. I take care of over three thousand patients at risk every day for sudden cardiac death from genetic heart disease. We've been reassuring them since February, March, that COVID-19 is not spooky for their heart, or they're not at greater risk of having a bad outcome. And then, they started hearing this last week that this virus is attacking the heart muscle left and right, and saying, "That's not a good thing to happen if it happens to my long QT heart or my genetic heart part. And what's the deal here?" And so, we thought we needed to clear the air and restore some semblance of balance to the universe, and that's why I threw down the penalty flag.”

GB: It's been the topic dujour. In light of the Big 10 shutting it down, same for the Pac-12, myocarditis. Let's pull back a little bit for those who are still learning about this word that they didn't know existed maybe a week ago, but it has existed for years, decades really. What is myocarditis, and what is its direct correlation and relationship with COVID-19?

Dr. Ackerman: ”Yeah. Myocarditis, simply speaking, is an infection of or inflammation of the heart muscle. Like you said, it's been around for decades. We have a Myocarditis Foundation, which is a wonderful foundation. There are millions of people who have had myocarditis. You can get it for a lot of reasons. The primary reason for our discussion are viruses. There's all sorts of viruses that can infect and inflame the heart muscle, and it happens during flu season. Influenza can do it. The common cold, adenovirus can do it. Lots of viruses can do it. And this news about SARS-CoV-2 coronavirus infecting the heart muscle is actually old news. We've known about this since February, March. We and others have published about it. We know how this virus steals, and gains, and hijacks a receptor on the heart muscle to gain entry into the heart cell and try to do its damage.”

Dr. Ackerman: ”So, that's not new news. The things that started to happen was the anecdote started to emerge. That then gets in front of true evidence. And the anecdotes become powerful pictures, and everybody starts saying, "We're playing with fire." But we have myocarditis a lot. Will we have more with this virus? It looks like the answer could be "yes." So, we have to give it respect. This virus deserves a lot of respect. But the paper that was cited last month is showing that this virus damages the heart in a lot of people with COVID-19, I thought that was a completely inappropriate paper for a variety of reasons. And we can talk about those and unpack those reasons to be using against otherwise healthy 18 to 24-year-old athletes.

GB: Bingo. Let's talk about it among 18 to 24-year-old athletes because those are the ones going to be participating in the actual games themselves. In the SEC, ACC, Big 12, they hope that means they're playing this fall. It's being seen anecdotally as a huge reason for going ahead and hit the pause button in the Big 10, in the Pac-12. But why did you think there were some fallacies in that research?

Dr. Ackerman: “Well, I think it's sort of apples and watermelons. It's not a fair comparison. That paper, the investigators in Germany are really good. The paper's really interesting, but the paper is about a hundred people with COVID-19. One hundred. Those hundred, their median age was 50-year-olds, my age.”

GB: Interesting.

Dr. Ackerman: ”Immediately, that's a foul. You cannot transfer a finding from 50-year-olds to 18 to 24-year-olds with no comorbidity. The other thing was the way they define the injury. They use a machine, a cardiac MRI, and they show that 78 out of the hundred had abnormal cardiac MRI findings. Now, will that be true in the 18 to 24-year-olds? Time will tell. We don't know. It may be. We also don't know what does it actually mean? Is that clinically significant myocarditis, for which I, as a clinician, can easily diagnose? Or is that a radiographic MRI machine finding for which, if we did that test during the annual flu season, or when somebody says, "I have the flu," and we got that test two weeks later, would the MRI show some findings after the normal flu infection?”

Dr. Ackerman: “And so, we don't know exactly the significance of those findings, even in the 50-year-olds. And we just cannot immediately transfer those findings and say, "That means this is unacceptably spooky and dangerous to an otherwise healthy 18 to 24-year-old." Not fair. I could never do that with any paper I published saying, "Here are my findings in 50-year-olds, and these findings in 50-year-olds, I'm going to immediately apply to my 20-year-old patients and call that a 'fair game.'" Can't do that.”

GB: Simply asked here, how at risk are college-age, high-performance athletes who contract COVID-19 and get myocarditis? How at risk are they? What does life look like for them? Can they not play for a significant amount of time? Can they play through it? What do you think needs to happen? How at risk are they?

Dr. Ackerman: “Yeah, that's a great question. There are two different questions. One is if you don't have the infection, can we do our season? Right?

GB: Yes.

Dr. Ackerman: “The other is what do we do for those athletes who are already SARS-CoV-2 positive? They have been infected. Or they're not only infected, but they're also symptomatic. And because of what we know about myocarditis, we need to follow the guidelines that have been out there for a long time. So, if there's an athlete clinically diagnosed with myocarditis, they're going to be in the penalty box for a long time. Their season may be over. The team physicians are going to be incredibly cautious to make sure that if it did involve the heart, ‘if’ because it doesn't involve the heart most of the time. If it did and their cardiac tests were abnormal, the team physician is going to be waiting until all cardiac tests have returned clean as a signal before they're going to return that COVID-19 athlete with symptoms of myocarditis back onto the field.”

Dr. Ackerman: “We need to be incredibly careful in the COVID-19 athlete who already has shown us myocarditis signs. But now, if they don't have any features and if the cardiac tests are absolutely normal, I think we can safely return to play an athlete who just got the virus because if the virus didn't do anything to the heart, we don't need to put them in the provisional penalty box because, theoretically, it might somehow, maybe, possibly do something to the heart later on. It's a risk. The risk, I cannot declare is zero, but the risk in that person is low. The risk in the athlete or non-athlete. Remember, this virus can do the non-athletes on the student campus just as well as the athletes.”

Dr. Ackerman: “And so, it doesn't care if you're an athlete or a non-athlete. If you just get the virus and you're otherwise asymptomatic, we can take precautionary measures, and I think we could safely return to play many if their heart was normal to begin with.”

GB: If you got a call from a conference, college conference commissioner, would you say to play or not play? Safer to not play. But with everything going on, Dr. Ackerman, what would your advice be?

Dr. Ackerman: “I would simply tell anybody who was interested in my opinion to not use the heart as the reason to cancel the season. The conferences may have other reasons like the virus is like wildfire in their conference, in their schools, in that population. We don't have any control. We're not satisfied with testing. We're not satisfied with our quarantine measures. We don't think the landscape is acceptable from all of the logistics. But do not use the heart as the reason to cancel the season. There could be other reasons, and the debates are out there, and we will always debate it, and I respect the debate, but I would just say, "Do not stand behind the heart as your reason for canceling the season."

GB: Is it fair to say the Big 10 and Pac-12 were knee-jerk in their decisions this week?

Dr. Ackerman: “No. I couldn't say that. I have no information about that. I know of many of the medical advisors in for those conferences. I highly respect them. I like them. One of them is a good friend. So, no. I think people have been doing their absolute best with the data set they have. And a lot of times, things are perspective. And I just try to bring a different perspective to those conferences who ask my perspective of how do we navigate a non-zero risk scenario? You already indicated, Gabe, football's dangerous. There is a measurable non-zero risk of a catastrophic head injury this season, spine injury, lots of things can happen. There is a non-zero risk when the fan base and the student body drives down the interstate that they're going to get hit by a person who was texting while driving.”

Dr. Ackerman: ”Life is a non-zero risk game. And so, we're trying to weigh the risks and benefits in the balances. I also told the Big 12 conference, as you know, that one, the virus doesn't care if you're an athlete or a non-athlete. So, it's there on the campus. Two, that if we disqualify a season, we're basically disqualifying an athlete, and there is guaranteed measurable mental health consequences that are going to take place. Will we measure them? That doesn't make the news. But those athletes, because I've seen it for 25 years now, athletes who got disqualified because of a variety of medical reasons, some of them have great resiliency and did great afterwards. So, you have to weigh that in the balance.”

Dr. Ackerman: “There is much that has to be weighed in the balances. And I think those conference who said, "The balance says the season should be canceled," have their reasons. Those that waited in the balance and says, "I think, for now, we are comfortable and confident in our strategies, and let's go forward, proceed with caution. New evidence comes in, we may have to pivot on a dime." So, this is going to be a rollercoaster ride. This is not going to be slow and steady, and people need to be ready for it. There's going to be, in the analysis, looking back, we're going to say, "Boy, some of these decisions were brilliant and had tremendous foresight." We're going to look back and say, "Some of these decisions were major blunders," and time will tell.”