COVID-19 myocarditis illusions: A new cardiac MRI study raises questions about the diagnosis

BY ANISH KOKA

One of the hallmarks of the last two years has been the distance that frequently exists between published research and reality. I’m a cardiologist, and the first disconnect that became glaringly obvious very quickly was the impact COVID was having on the heart. As I walked through COVID rooms in the Spring of 2020 trying to hold my breath, I waited for a COVID cardiac tsunami. After all social media had been full of videos from Wuhan and Iran of people suddenly dropping in the streets. My hyperventilating colleagues made me hyperventilate. Could it be that Sars-COV2 had some predilection for heart damage?

Happily, I was destined for disappointment. There never was a cardiac tsunami from COVID.

There were, unhappily, lots of severely ill patients with lungs that were whited out who quickly developed multi-organ dysfunction while hospitalized. The lungs were where almost all the action was. Every other organ got hit hard because of the systemic illness that unfortunately often is a downstream result of a severe respiratory illness. Cardiac Cath labs waiting for some major influx of COVID heart damage not only didn’t see patients presenting with COVID heart attacks, but they idled as patients terrified of coming to the hospital stayed home rather than come to the hospital with chest pain. (Public health messaging about COVID appears to have kept people away from hospitals, and autopsy series of deaths during the pandemic found that reduced access to health care systems (for conditions such as myocardial infarction) was further likely to be identified as a contributory factor to death than undiagnosed COVID-19).

So imagine my surprise when I saw peer-reviewed research based on a cardiac MRI study come out in 2020 suggesting that 78% of patients who survived COVID may have significant heart damage. A more detailed read of the paper, of course, threw up massive problems. The article and authors were more suited as writers for Oprah and Dr. Phil than for a well-respected academic journal. But the damage was done, and the notion that COVID was attacking hearts spread via a social media influencer class that should have had the credentials and smarts to know better, but clearly didn’t.

Reminder for those puzzled about how we got here : Pandemic expert Yaneer Bar-Yam , also Complex systems Physicist tells us in the Summer of 2020 that 50% of people with COVID will have the type of heart damage where the heart “tears itself with every beat” pic.twitter.com/oyhGrkT56n

— Anish Koka, MD (@anish_koka) January 8, 2022

This was all completely bonkers to witness in real-time. But it got worse.

The next blow to reality came from epidemiologists seeking to capitalize on journals’ hunger for COVID research. They were aided by sloppy electronic medical record databases that contained lots and lots of ICD10 diagnoses. The specific problem when it comes to diagnosing myocarditis by ICD10 codes only is that there is remarkably little work that goes into verifying the patient actually has myocarditis. When someone presents to the hospital with chest pain and clinicians go through the appropriate steps to diagnose myocarditis (exclude other diagnostic possibilities, supportive imaging/biopsy data), one can be fairly certain the diagnosis is indeed correct. But too often, a diagnosis of myocarditis is attached to severely ill patients who have evidence of myocardial injury as a result of the severe illness that brought them to the hospital. Importantly these diagnoses get attached to patients despite missing the traditional clinical context of myocarditis (chest pain) or imaging/biopsy evidence. The exact same pattern of heart damage would likely have been seen after an illness for the flu virus, or really any other diagnosis that resulted in a severe medical illness.

But the politics was all-pervasive. Vaccine myocarditis was recognized as a serious adverse event of concern in April of 2021, and a growing public outcry about the danger could only be quelled by data that showed COVID myocarditis was an even riskier proposition. And so the CDC gave marching orders to convince the population to be vaccinated trotted out their own bad EMR studies to show COVID myocarditis was a far greater risk than vaccine myocarditis.

The party told you to reject the evidence of your eyes and ears. It was their final, most essential command. – George Orwell, 1984

The evidence of your eyes and ears can only be rejected for so long apparently. A recent paper from the United Kingdom attempted to examine the mechanism of cardiac injury in COVID hospitalized patients by performing cardiac MRIs within 28 days of a discharge for a COVID hospitalization. Two prospective control groups were recruited, comprising 64 patients with COVID-19 and normal troponin levels (COVID+/troponin−) and 113 patients without COVID-19 or elevated troponin levels matched by age and cardiovascular comorbidities (COVID−/comorbidity+). Cardiac MRI studies that go hunting for a particular diagnosis are always going to be plagued by overdiagnosis and this study is no exception. 1.7% of the community control group were diagnosed with recent myocarditis using MRI criteria – a rate that is well in excess of the 0.01-02% background rate of myocarditis. The vast majority of MRI abnormalities found in recently hospitalized COVID patients are related to pre-existing cardiac disease. The accompanying editorial concurred.

Data from COVID-Heart provide reassuring evidence that myocarditis, once predicted to be an emerging public health crisis attributable to COVID-19, is relatively uncommon even among hospitalized patients and is less virulent than predicted during the early days of the pandemic. It is likely that elevated cardiac troponin concentrations during COVID-19 in many patients do not reflect significant new myocardial injury and fibrosis, but rather cardiac troponin release from vulnerable hearts with pre-existing scar in the setting of severe illness

This whole saga should raise a lot of questions about the role of the medical community, and specifically the academic cardiology community in fanning the flames of the panic that directly lead to the massive societal disruption of the last 2 years.

Essentially a number of motivated researchers rushed bad studies to publication in major journals that suggested COVID had a special proclivity for heart damage. This was, in part, what was used to support vaccine mandates, school closures, and minimizing vaccine myocarditis!

After all, who cares about vaccine myocarditis in young boys and men, if the prevalence of covid myocarditis was higher? But it’s not. And it never was.

The epidemic of COVID myocarditis was a creation of really bad academic imaging researchers and epidemiologists who went on Electronic Medical Record diagnosis code data mining expeditions. The safeguards that exist specifically to safeguard the truth – the CDC, peer review, and academic culture not only failed to contain the spread of this myth but actively participated in the promulgation of misinformation!

The damage is far from contained. Epidemiologists from Scandinavia just released another comparison of vaccine myocarditis, covid myocarditis, and conventional myocarditis. There are all sorts of conclusions that are drawn based on the data, but the same disconnected-from-reality formula applies: use a database of diagnosis codes to arrive at relative rates of myocarditis, without trying to establish the veracity of the myocarditis diagnosis clinically by chart review. As a result, these are hopelessly confounded comparisons that are almost completely irrelevant. When questioned on the matter, first author Anders Hviid suggests ignoring the COVID-19 myocarditis data, and just focusing on the vaccine myocarditis data.

Clinical input is always appreciated. But our paper is really about vax-myo. You could ignore the c19-myo without the conclusions changing much.

— AndersHviid (@anders_hviid) February 5, 2023

Recall that the vaccine myocarditis diagnoses are much less likely to suffer from diagnostic uncertainty because their primary presentation involves a formerly healthy individual presenting with chest pain and cardiac biomarker release indicating cardiac cell death shortly after vaccine administration. All of these patients are then ruled out for other causes of chest pain, and then almost invariably get cardiac imaging or a biopsy to support the diagnosis of myocarditis. Focusing only on the vaccine myocarditis outcomes as Dr. Hviid recommends is not pretty.

So the OVERALL risk of getting myocarditis or HF from *vaccination* (all doses combined) appears higher than post covid, but per myo case, the vaccine myo appears be milder YET "six patients with myocarditis after vaccination died within 90 days of admission to hospital" pic.twitter.com/BTA4MkN27Z

— Tracy Høeg, MD, PhD (@TracyBethHoeg) February 4, 2023

Of the 530 cases of diagnosed vaccine myocarditis, 22 had a diagnosis of heart failure within 90 days of follow-up, and 6 died. Frustratingly, without any additional clinical information, it is impossible to read any further into this data. Were the 6 deaths related to vaccine myocarditis? How bad was the heart failure reported? I have no idea.

One hopes the recent imaging studies will put an end to the fictional beast of COVID-19 myocarditis, but I’m doubtful.

Anish Koka is a Cardiologist. Follow him on twitter @anish_koka

I have to make the obligatory post-script here that I oversaw the administration of hundreds of mrna vaccines starting in March of 2021 in my cardiology clinic. The vaccine efficacy data for the original data was from thousands of patients and I certainly felt given the devastation wreaked on many of my patients in 2020 that the vaccines were the best chance of avoiding morbidity and mortality. The process to get the vaccines from the city department of health was a somewhat arduous 3 month process, and once the vaccines were on hand, there were daily reporting requirements that I dutifully performed for the many months we were administering vaccines. To accommodate the rush of patients, employees, volunteers, and conscripted children worked multiple weekends to administer the vaccines. So I’m especially disgusted by medical colleagues who label any concerns registered about vaccine adverse events as “anti-vaxx”. Registering concern over a vaccine adverse event does not make doctors or patients “anti-vaxx”. It makes them pro-vaxx!