News Scan for Oct 27, 2020

COVID-19 guidance for athletes
COVID heart damage on ultrasound
Two more Ebola deaths in DRC
H5N8 avian flu in Russia

Experts offer return-to-play guidance for COVID-19 in athletes

Sports cardiologists in JAMA Cardiology yesterday updated guidance for athletes returning to play (RTP) after COVID-19 infection. The authors recommended a risk stratification approach, with screening for cardiac injury only for athletes with severe disease or preexisting cardiovascular (CV) conditions.

The prevalence of cardiac pathology in infected athletes is not fully understood, but publicized reports of athletes with suspected COVID-19–induced myocarditis and studies showing myocardial injury in individuals even with mild or asymptomatic infection have generated concern about how to safely manage COVID-19 in athletes.

The American College of Cardiology issued RTP recommendations in May after data emerged showing cardiac injury in COVID-19–hospitalized patients, including myocardial inflammation and myocarditis. Those recommendations directed asymptomatic athletes to restrict activity for 2 weeks from the date of a positive test result, followed by slow resumption of activity and risk stratification testing—electrocardiogram, echocardiogram, troponin testing, cardiac magnetic resonance (CMR) imaging—only if symptoms of cardiac involvement occurred. Symptomatic athletes were advised to refrain from exercise for 2 weeks following symptom resolution, followed by CV evaluation using biomarkers and imaging, and cardiac magnetic resonance (CMR) imaging if indicated. 

The updated recommendations largely align with the earlier guidelines, advising no additional testing or risk stratification for asymptomatic athletes returning to activity after the Centers for Disease Control and Prevention (CDC)-recommended self-isolation period.

The authors recommend that high school athletes have a formal pediatric or pediatric cardiology evaluation with further CV risk stratification and testing only if cardiac symptoms warrant. Similarly, routine RTP CV assessment was not recommended for masters-level athletes (35 years and older) unless they have persistent symptoms or preexisting CV conditions.

Athletes of all ages with moderate or severe COVID-19 infection are recommended to receive comprehensive CV risk stratification with testing that may include a clinical evaluation, electrocardiogram, blood troponin levels, echocardiography, CMR, and ambulatory rhythm monitoring.  

Acknowledging the need for further data, the authors observed that risk stratification testing among athletes yielded few cases of cardiac pathology. In an accompanying commentary, three sports medicine experts note, "Although there remains uncertainty, it is promising that early experiences have observed that nearly all athletes who recover from mild COVID-19 infection do not develop significant cardiovascular pathology."
Oct 26 JAMA Cardiol study
Oct 26 JAMA Cardiol commentary


Echocardiograms reveal COVID-related heart damage tied to mortality

An international study yesterday in the Journal of the American College of Cardiology evaluated cardiovascular ultrasound (echocardiogram) data for hospitalized COVID-19 patients, revealing cardiac structural abnormalities and increased in-hospital mortality rates in nearly two thirds of patients with cardiac injury.

Myocardial injury (defined as an elevation in cardiac troponin levels—proteins released when heart muscle is damaged) is common in patients hospitalized with COVID-19, but the mechanisms of cardiac injury remain unclear and imaging data has not yet been evaluated. This multicenter study included 305 hospitalized COVID-19 patients in seven hospitals in New York City and Milan, Italy, who underwent cardiac ultrasound—transthoracic echocardiographic evaluation (TTE)—and electrocardiographic (ECG) evaluation during hospital stays from Mar 5 to May 2.

Myocardial injury was found in 190 patients (62.3%), along with higher rates of ECG abnormalities, higher troponin and inflammatory biomarkers, and an increased prevalence of major TTE abnormalities compared with patients without myocardial injury. In-hospital mortality rates differed markedly: 5.2% in patients without myocardial injury, 18.6% in patients with myocardial injury, and 31.7% in patients with myocardial injury and TTE abnormalities. After the researchers adjusted for variables, they found that myocardial injury with TTE abnormalities was associated with a significantly higher risk of death (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.27 to 11.80; P = 0.02).

In a commentary in the same journal, experts not involved in the study recommended the routine use of biomarkers and TTE as a valuable tool for accurate patient risk stratification, prediction of severe disease, and identification of appropriate patient treatments.

"Early detection of structural abnormalities may dictate more appropriate treatments, including anticoagulation and other approaches for hospitalized and post-hospitalized patients," said study author Valentin Fuster, MD, PhD, in a Mount Sinai Hospital news release.

"Echocardiography is the only imaging modality that can be taken to the bedside and safely used for patients, including those on ventilators," said coauthor Lori Croft, MD, in the Mount Sinai release. "Our findings will help guide care of Covid-19 patients during a critical time."
Oct 26 J Am Coll Cardiol study
Oct 26 J Am Coll Cardiol commentary
Oct 26 Mount Sinai Hospital news release


DRC officials note 2 fatal Ebola cases listed as probable, no new cases

Two more probable cases of Ebola—both fatal—have been reported in the Democratic Republic of the Congo (DRC) outbreak, bringing the total to 130 cases (119 confirmed and 11 probable), 55 deaths (42.3% case-fatality rate), and 75 recoveries.

These numbers, updated in a tweet today, reflect the latest information from the World Health Organization (WHO) Africa regional office as the agency follows the 11th Ebola virus outbreak that started in the nation's Equateur province in June.

Twenty-eight days have gone by without any new confirmed cases, WHO officials said, and if this holds for 12 more days, the outbreak will be officially declared over.
Oct 27 WHO African Region tweet
Oct 1 CIDRAP update
CIDRAP past updates


Russia reports more H5N8 avian flu outbreaks in poultry and wild birds

Animal health officials in Russia reported more highly pathogenic H5N8 avian flu outbreaks in poultry and wild birds, according to three new notifications today from the World Organization for Animal Health (OIE).

Russia has reported a sporadic stream of H5N8 outbreaks in the southwest of the country, and veterinary officials in the United Kingdom have warned about the increased risk for further spread into Europe by migratory birds.

The latest outbreaks in Russian poultry are from newly affected oblasts. One in the Republic of Tatarstan began on Sep 30 in backyard birds, killing 183 of 1,220 susceptible poultry. The rest were culled as part of the outbreak response. Another outbreak occurred at a farm in Kostroma oblast, which started on Oct 10, killing 14,041 of 282,957 poultry. The surviving birds were destroyed.

Also, the country reported two more H5N8 outbreaks in wild birds, both in Tyumen oblast. The events began on Sep 6, involving six waterfowl, apparently found dead in two different locations.
Oct 27 OIE report on H5N8 in Russian backyard birds
Oct 27 OIE report on H5N8 at Russian poultry farm
Oct 27 OIE report on H5N8 in Russian wild birds

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