David Chao, MD: Investigating Both Sides of Myocarditis Divide

The two top college football conferences have often battled on the gridiron. Now comes an ideological battle over potential COVID induced heart issues and whether collegiate contests should be played given the risk.

The Big Ten just cancelled all fall sports reportedly over myocarditis concerns while the SEC intends to proceed as planned.

What is myocarditis? "Myo" means muscle, "card" as in cardio is short for heart and "itis" is inflammatory disease. Thus it means inflammatory disease of the heart muscle. 

Debate is healthy and it happens in medicine too, especially when things are new and evolving as is the case with this novel coronavirus. Believe it or not, doctors don't always agree. In fact, they often differ. Just like four general managers advised by team doctors passed on Tua Tagovailoa and several other teams where rumored to have removed him from the draft board for the hip, but at No. 5, Miami pulled the trigger. And let's not forget, any decision made by humans is fraught with the influences of personal experiences and feelings.

Time will tell who is right.

There are no clear answers but many differing opinions. In the meantime, I will argue out both sides of the situation with the top 10 questions you might have. I am not a cardiologist or infectious disease expert but as a former NFL head team physician, I would have been in a place to collect data and weigh in on both sides. I will argue each point from the theoretical perspective of the Big Ten and then counterpoint from the potential viewpoint of the SEC. 

(Why does the Big Ten go first? Because they made the decision to cancel sports. Why does the SEC go last? Because someone has to.)

1) Why cancel the season? 
Big Ten: As doctors advising our league, we must adhere to the Hippocratic Oath which says "first, do no harm". Given the myocarditis issue, this is not just the flu. One can't mess around with the heart, head or spinal cord. There is too much risk for college kids who aren't paid.

SEC: Sure there are reports of myocarditis but in our clinical experience, the vast majority of college kids are asymptomatic or show minimal symptoms, so most won't have heart issues. The potential upside of sports outweigh the small risk and players are choosing (not being forced) to play. That is the opportunity that was promised to them when they enrolled and the thoughts of moving football to spring are not realistic as having two full seasons (Spring and Fall) in 2021 presents much greater health/injury risks.

2) What is the risk/worry with myocarditis?
Big Ten: When the heart muscle is inflamed, the electrical system housed within it can go haywire and that can lead to a cardiac arrhythmia. This can and has resulted in sudden death syndrome in non-COVID myocarditis situations. We cannot risk the lives of our students.

SEC: We would never risk the lives of our students either. Myocarditis only can develop with fever and symptoms of COVID, not just with positive tests. We monitor players and will do cardiac screening that will include EKG, echocardiogram, enzyme (troponin) testing and even cardiac MRI if needed. Young people don't drop dead walking around, only potentially with exertion, which we will not allow with any detection of even mild myocarditis.

3) Is the risk real or potential?
Big Ten: Yes it is real as we have found at least five cases of myocarditis in our athletes. We are aware of the reports from Italy as well as a Red Sox pitcher ruled out for the season. 

SEC: Yes, we are aware of the potential risk and reports in the medical literature. The risk for myocarditis exist whether COVID is contracted on the field, in the dorm or back at home.

4) Is the risk for arrhythmia worse for college athletes?
Big Ten: We don't know how COVID myocarditis is different than other models of myocarditis but we can't take that chance with our athletes as exertion is what brings out the arrhythmia leading to potential sudden death.

SEC: While we agree we don't exactly know how this type of myocarditis will act, the fact remains that we can detect the heart issue and exclude the athlete from exertion to save them from arrhythmia versus if they are on their own without the tests or monitoring and workout unsupervised.

5) Are there long term risks?
Big Ten: Maybe, we don't know what the long term risks are from myocarditis, pericarditis or even other lung scarring. When dealing with the vital organs of college students we should not risk it as it can happen if our schools do the right thing with precautions. 

SEC: Agree that we don't know but other models of myocarditis have not presented with long term issue. We agree that even if we do the right things to protect our athletes, we can't guarantee no infections but let's not forget that risk for heart issues is same if someone gets COVID in their home communities. Also we have dealt with myocarditis from other sources like cold/GI viruses, staph/strep etc., before too.

6) Is there heart risk to all people who test positive?
Big Ten: Potentially yes, because if you get COVID, some studies show up to 15% of young people can get myocarditis.

SEC: No, testing positive for coronavirus alone will not lead to myocarditis. That potential risk only exists if you get the disease of COVID (or from other virus/bacteria) with fever and symptoms.

7) Why after six months of prevalence in the USA is the heart issue only to come to light now?
Big Ten: We always were aware of myocarditis risk but a key study published just two weeks ago in the major medical publication Journal of the American Medical Association (JAMA) alerts us that a whopping 78% of patients had myocardial inflammation. This study can't be ignored. 

SEC: Yes, we read JAMA too but that study involved patients whose youngest age was 45, used cardiac MRI and was only an imaging study. In other words, it was a much older demographic with MRI findings of questionable clinical significance. 

8) How can so many other sports be playing?
Big Ten: We only control what we can control. Given the collegiate atmosphere, we don't think it is right to play. We can't take the chance of harm.

SEC: We look at the highest risk league for cardiac arrhythmias, the NBA. Their doctors allow young, college age individuals to play with monitoring. Basketball has been hit hardest by sudden cardiac deaths and the sport is acutely aware of the heart safety issues yet they continue to play.

9) Can you play with myocarditis?
Big Ten: No. Any small risk of arrhythmia with myocarditis is too high.

SEC: Here we agree. But that is why we monitor and test.

10) Is this just all about liability?
Big Ten: Partially yes. That is a reality of life nowadays. Also there can be no true waiver. Also remember two of our university presidents are experts in the field. The Presidents ultimately make the call and Michigan's is a professor of microbiology/immunology and Michigan State is led by a doctor specializing in infectious diseases

SEC: We are acutely aware of potential liability and have the resources to screen and test to protect our athletes who participate voluntarily. We are comfortable with informed consent and close monitoring as we always have done with myocarditis that develops from non-COVID infections like staph/strep or other viruses.

BONUS QUESTION: Is the other league wrong with their approach?
Big Ten; No. The SEC and its doctors just look at the same issue from a different perspective and they say "glass half full".

SEC: No, The Big Ten and its doctors just look at the same issue from a different perspective and they say "glass half empty".

Written by
David Chao, MD -- known digitally as Pro Football Doc -- is an expert contributor for Outkick. Chao spent 17 seasons as the team doctor for the San Diego Chargers (1997-2013) and is part of the medical team at OASIS in San Diego where he treats and specializes in orthopedic sports injuries, working with high-profile professional athletes from the NFL, NBA, and MLB.