CMR in Patients With COVID-19

Petersen SE, Friedrich MG, Leiner T, et al.
Cardiovascular Magnetic Resonance for Patients With COVID-19. JACC Cardiovasc Imaging 2022;15:685-699.

The following are key points to remember from this state-of-the-art review about cardiovascular magnetic resonance imaging (CMR) in patients with coronavirus disease 2019 (COVID-19):

  1. With acute COVID-19, reports of CMR use have been infrequent, partly due to concerns regarding infection control in the hospital setting.
  2. Numerous CMR studies obtained 1-5 months following discharge revealed abnormalities in 26-60% of individuals who were hospitalized for COVID-19. Low rates of CMR abnormalities were observed in patients who had mild or asymptomatic COVID-19.
  3. Among athletes recovering from COVID-19, CMR studies have reported prevalence of myocarditis-like findings in 0-15%. About 50% with myocarditis-like findings on CMR were asymptomatic in single-center studies, and the vast majority had a normal electrocardiogram and troponin. Serious adverse outcomes can result from resuming exercise too quickly after viral infection in athletes or with occult myocarditis. Myocarditis, unrelated to COVID-19, is responsible for 4-8% of sudden cardiac deaths in athletes or can result in long-term complications (e.g., myocardial scarring, arrhythmias, and myocardial dysfunction).
  4. In multisystem inflammatory syndrome in children (MIS-C), CMR studies performed during or shortly after initial hospitalization frequently identified capillary leak, hyperemia, late gadolinium enhancement, and myocardial edema. Studies performed 2-3 months post-discharge frequently showed no abnormalities.
  5. The publication describes expert consensus recommendations regarding CMR in COVID-19 from an international panel, summarized below.
  6. CMR should be considered only if results would likely impact clinical decisions.
  7. In acute COVID-19, CMR should be considered for patients with a high pretest probability for acute myocardial injury due to inflammation, after excluding acute coronary syndrome.
  8. In those convalescing from COVID-19, CMR can be considered in patients: (a) with unexplained, persistent, or recurring cardiovascular symptoms as part of a systemic inflammatory post–COVID syndrome >4 weeks after COVID-19 recovery; and (b) with prior CMR in the acute care setting showing clinically significant acute myocardial injury; follow-up CMR should be performed ≥4 weeks after the initial acute CMR.
  9. In high-performance athletes following recovery from COVID-19, CMR should be considered: (a) prior to resumption of training in those with history of severe COVID-19 or in those with history of moderate COVID-19 and high-pretest probability of myocardial injury by diagnostic testing or clinical suspicion; or (b) in those who have returned to play and have new cardiovascular symptoms with suspicion of myocardial injury.
  10. In MIS-C, CMR should be considered:
    • If clinical suspicion of myocardial injury or substantially decreased ventricular function during hospitalization for acute illness, particularly if not improving clinically.
    • Approximately 1-6 months after acute MIS-C presentation in patients with prior moderately or severely diminished left ventricular systolic function or baseline abnormal CMR.
    • If concern for coronary artery aneurysm.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Magnetic Resonance Imaging, Sports and Exercise and Imaging

Keywords: Acute Coronary Syndrome, Aneurysm, Arrhythmias, Cardiac, Athletes, COVID-19, Death, Sudden, Cardiac, Diagnostic Imaging, Edema, Electrocardiography, Gadolinium, Heart Failure, Hyperemia, Inflammation, Ischemia, Magnetic Resonance Imaging, Myocarditis, Pediatrics, SARS-CoV-2, Secondary Prevention, Troponin, Ventricular Function

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