September 9, 2020

To:      

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.

Studies^1–3 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

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.