The publication of several studies using cardiac magnetic resonance imaging raised public fears over increased risk to the heart in patients following infection with COVID-19. A group of physicians wrote the following letter warning against the use of CMRI in asymptomatic people following infection.

September 9, 2020

To:    American College of Cardiology
American College of Chest Physicians
American College of Physicians
American College of Radiology
American Heart Association
American Society of Echocardiography
American Thoracic Society
European Association of Cardiovascular Imaging
European Society of Cardiology
European Society of Radiology
Heart Rhythm Society
Infectious Disease Society of America
North American Society of Cardiovascular Imaging
Radiologic Society of North America
Society of Cardiovascular Magnetic Resonance
Society of Critical Care Medicine
Society of General Internal Medicine
Society of Hospital Medicine

Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

Studies123 investigating the prevalence of myocarditis in patients with recent COVID-19 have found features of subclinical myocarditis on cardiac magnetic resonance (CMR) imaging in patients without symptoms. Some commentators have raised concern that COVID-19 may lead to frequent, serious long-term cardiac sequelae even among people who have had mild infection and are currently asymptomatic.

We wish to emphasize that the prevalence, clinical significance and long-term implications of CMR surrogates of myocardial injury on morbidity and mortality are unknown. Further, it is unclear if the elevated T1 and T2 flagged in these studies are clinically significant, particularly in isolation, if treatment is needed, and, if so, what the management should be.  These important questions should inspire future prospective studies.

Nonetheless, these reports have attracted significant media coverage, at times amplified by speculation on possible clinical implications, thus generating substantial anxiety amongst members of the general public. As a result, we are aware that some individuals are seeking CMR testing despite the absence of cardiac symptoms. We believe that, given the preliminary nature and limitations of the current evidence, testing asymptomatic members of the general public after COVID-19 is not indicated outside of carefully planned and approved research studies with appropriate control groups.

In light of your societies’ standing in the community and advocacy against low-yield testing and low-value medical care through your sponsorship of the Choosing Wisely4, Image Wisely5, and other similar campaigns, we request that you offer clear guidance discouraging CMR screening for COVID-19 related heart abnormalities in asymptomatic members of the general public.

Sincerely,

Venkatesh L. Murthy, MD, PhD, FACC, FAHA Rubenfire Professor of Preventive Cardiology Division of Cardiovascular Medicine University of Michigan, Ann Arbor, MI USA

Daniel J Morgan MD, MS, FIDSA, FSHEA, Professor of Epidemiology and Public Health and Infectious Diseases University of Maryland School of Medicine, Chief Hospital Epidemiologist, VA Maryland Healthcare System Baltimore, Maryland USA

Vinay Prasad MD MPH, UCSF, San Francisco, CA, USA

Edward J. Schloss, MD, FHRS, Division Chief, Cardiac Electrophysiology, The Christ Hospital, Cincinnati, OH USA

Stephen A. McCullough, MD, Assistant Professor of Medicine, Department of Medicine, Division of Cardiology, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, NY USA

Christos Argyropoulos, MD, PhD, FASN, Division Chief, Nephrology, University of New Mexico School of Medicine, Albuquerque, NM USA

Ibrahim Halil Tanboga, MD, PhD, Professor of Cardiology and Biostatistician, Nisantasi University & Hisar Intercontinental Hospital, Department of Cardiology, Istanbul Ataturk University, Medical School, Department of Biostatistics, Erzurum, Turkey

David L. Brown, MD, Professor of Medicine, Washington University School of Medicine, St. Louis, MO USA

Ritu Thamman MD, Assistant Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA

Zainab Samad, MBBS, MHS, Professor of Medicine,, Aga Khan University, Karachi, Pakistan

John Mandrola, MD, Cardiac Electrophysiologist, Baptist Health Louisville, Louisville, KY USA

Ethan J. Weiss, M.D. UCSF, San Francisco, CA USA

Rohin Francis, MBBS, Cardiology specialist trainee, Essex Cardiothoracic Centre, Basildon, UK

Rory Hachamovitch, MD, MSc, FACC, MASNC, Staff Cardiologist, Cleveland Clinic, Cleveland, OH USA

Jeremy B Sussman, Associate Professor Of Medicine, University of Michigan, Ann Arbor, MI USA

Marcio Sommer Bittencourt MD, MPH, PhD, FACC, FESC, FAHA, Staff Cardiologist, Department of Internal Medicine, University Hospital – University of Sao Paulo, Sao Paulo – Brazil

David J. Cohen, MD MSc, Professor of Medicine, University of Missouri-Kansas City, Kansas City, MO USA

Joshua E. Levenson, MD FACC, University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA USA

Benoy N Shah,MD FRCP FESC, Consultant Cardiologist, Southampton General Hospital, UK, President, British Heart Valve Society

Fernando G Zampieri, MD, PhD, Intensivist, Research Coordinator, HCor Research Institute, São Paulo, Brazil

Leticia Kawano-Dourado, MD, PhD, Respiratory medicine physician and researcher, HCor Research Institute, São Paulo, Brazil, Pulmonary Division, Heart Institute (InCor), Medical School of the University of Sao Paulo, Sao Paulo, Brazil; INSERM UMR 1152 – University of Paris Diderot, Paris, France

João L. Cavalcante, MD, FACC, FSCMR, Imaging Cardiologist and Director of Cardiac MRI and Structural CT Labs, Minneapolis Heart Institute, Minneapolis, MN, USA

Florian Zores, MD, Cardiologist, Specialized Medical Center & Ellipse Center, Strasbourg, France

Adam Cifu, MD, Professor of Medicine, University of Chicago, Chicago Il, USA

Ash Paul MPH, FFPH, Consultant in Public Health, NHS South West London CCG, London SW19 1RH UK

Ashish Aneja MD FACC FASE FSCMR, Staff Cardiologist, Associate Professor of Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH USA

David R. Tomlinson BM BSc MD, Consultant Cardiologist and Electrophysiologist and MedRxiv Affiliate, University Hospitals Plymouth NHS Trust, Plymouth, UK USA

Michael E. Johansen MD MS, Assistant Residency Director, Grant Family Medicine, Columbus, OH USA

Joseph Selvanayagam MBBS (Hons) FRACP DPhil FESC FSCMR, Professor of Cardiovascular Medicine, Flinders University, Senior Consultant Cardiologist, Director of Imaging, Flinders Medical Centre, Adelaide, Australia

Brett W. Sperry, MD, Assistant Professor of Medicine, University of Missouri – Kansas City, Saint Luke’s Mid America Heart Institute, Kansas City, MO USA

Martin Ugander MD PhD, Professor of Cardiac Imaging, University of Sydney, Sydney, Australia

Jason H. Wasfy, MD MPhil, Director, Outcomes Research, Massachusetts General Hospital Heart Center, Assistant Professor, Harvard Medical School, Boston, Massachusetts USA

Constantine Raptis, MD, Director of Thoracic MRI and Co-Director of Emergency Radiology, Associate Professor of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, St. Louis, MO USA

Eric Strong, MD, Associate Professor of Medicine, Stanford University, Stanford, CA USA

Leon Menezes, BA BM BCh FRCR FRCP, Consultant Radiologist & Nuclear Medicine Physician, UCL Institute of Nuclear Medicine and Barts Heart Centre, London UK, Lead Nuclear Cardiology UCL Partners

Will Watson, MB BChir, Specialist Registrar in Cardiology, Oxford, United Kingdom

Edward J. Miller, MD PhD, FASNC, FACC, Associate Professor of Medicine (Cardiology) and Radiology & Biomedical Imaging ,Director, Nuclear Cardiology, Director, Cardiology Fellowship Program, Yale University School of Medicine, New Haven, CT USA

Marc R Dweck MD PhD FRCP FACC, Professor of Clinical Cardiology, University of Edinburgh, United Kingdom

Evelyn M Horn MD, Director Advanced Heart Failure and Pulmonary Vascular Disease, Professor of Clinical Cardiology, Weill Cornell Medicine

Saurabh Jha MBBS MRCS MS, Associate Professor of Radiology, University of Pennsylvania

Juan C. Lopez-Mattei, MD, FACC, FASE, FSCCT, FSCMR, Associate Professor, Department of Cardiology, Adjunct Associate Professor, Department of Thoracic Imaging, Co-Director, MD Anderson Cardiac Radiology Services, University of Texas MD Anderson Cancer Center

Dorian L, Beasley, MD, FACC, General and Interventional Cardiology, Indianapolis, Indiana

Erik Schelbert, MD, MS, FACC, Director, Cardiovascular Magnetic Resonance, Associate Professor of Medicine, University of Pittsburgh School of Medicine

Bogdan Enache MD, Cardiologist, Princess Grace Hospital, Monaco

David Nunan PhD, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK

Brahmajee Nallamothu, MD, MPH, Professor of Internal Medicine, University of Michigan Medical School – Ann Arbor

Yiannis S. Chatzizisis, MD, PhD, Professor of Medicine, Physiology and Engineering, Chief, Interventional Cardiology Section, Director, Cardiac Catheterization Laboratory, Director, Heart and Vascular Unit, Director, Cardiovascular Biology and Biomechanics Laboratory, Cardiovascular Division, University of Nebraska Medical Center, Omaha, NE, USA

Raj Mehta, MD, Family Medicine & Clinical Informatics, Assistant Program Director, Family Medicine Residency AdventHealth, Winterpark, FL USA

Saurabh Malhotra MD MPH FACC FASNC, Imaging Cardiologist, Director of Advanced Cardiac Imaging and Cardiac Stress Testing Laboratory, Division of Cardiology, Cook County Health, Associate Professor of Medicine (Cardiology), Rush Medical College, Chicago, IL, USA

Shelby Kutty, MD, PhD, MHCM, The Helen B. Taussig Professor, Director, Pediatric and Congenital Cardiology, Co-Director, Blalock Taussig Thomas Heart Center Johns Hopkins University School of Medicine

Ali N Zaidi, MD, Director, Mount Sinai Adult Congenital Heart Disease Center, Director, Academic Affairs, Childrens Heart Center, Kravis Children’s Hospital, Associate Professor, Medicine and Pediatrics Ichan School of Medicine at Mount Sinai, New York, NY

Pamela K. Woodard, MD, FACR, FAHA, FCCP, FSCMR, FNASCI, Hugh Monroe Wilson Professor of Radiology, Professor of Biomedical Engineering, Sr. Vice Chair, Radiology Research Facilities, Director, Cardiac MRI/CT, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA

References:

  1. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, Shchendrygina A, Escher F, Vasa-Nicotera M, Zeiher AM, Vehreschild M, Nagel E. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol [Internet]. 2020;Available from: http://jamanetwork.com/journals/jamacardiology/fullarticle/2768916
  2. Huang L, Zhao P, Tang D, Zhu T, Han R, Zhan C, Liu W, Zeng H, Tao Q, Xia L. Cardiac Involvement in Patients Recovered From COVID-2019 Identified Using Magnetic Resonance Imaging. JACC Cardiovasc Imaging [Internet]. 2020;Available from: http://www.sciencedirect.com/science/article/pii/S1936878X20304034
  3. Clark DE, Parikh A, Dendy JM, Diamond AB, George-Durrett K, Fish FA, Fitch W, Hughes SG, Soslow JH. COVID-19 Myocardial Pathology Evaluated Through scrEening Cardiac Magnetic Resonance (COMPETE CMR). medRxiv. 2020;2020.08.31.20185140.
  4. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–1802.
  5. Brink JA, Amis ES. Image Wisely: a campaign to increase awareness about adult radiation protection. Radiology. 2010;257:601–602.

Leave a Reply