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Cardiac Red Flag. Role of Cardiac MRI Dr Dan Sado Honorary Senior Lecturer, Kings College London Cardiology Co-Lead for Post COVID Syndrome in SE London Consultant in Cardiology and Cardiovascular MRI Clinical Lead, Kings College Hospital Training Programme Director for South Thames Cardiology Outline • To consider changes in mindset with COVID 19 • To look at MRI in myocarditis and pericarditis • To consider our 37 yr old patient from the chest pain side of things The March 2020 Lockdown address • To discuss OMS and OPS syndromesQuestion 1 (for Cardiologists – apologies to Radiology) • A trop T is measured on a patient in your emergency department with severe septic shock. • It comes back as 19 (normal <14) and is normal the next day and ITU call you for advice. • Does that troponin interest you in terms of clinical care and potential cardiology involvement?COVID 19 – Changing the way we think? BUT • So, it appears most Cardiologists generally leave that conversation feeling like the result is not relevant to make any clinical changes. • HOWEVER… • This is as much a question about Philosophy as it is science.. What about if rather than Septic Shock, the patient has COVID 19 and this is April 2020? • Would the answer have been different? • What is the impact of this on how you might report a CMR scan? COVID 19 and CMR – The Challenges • 1) Mindset changes in clinicians and clinician academics MRI in Myocarditis • LV function • LV myocardial inflammation • LV ScarringMRI of a Y oung Patient with covid Myocarditis PV LA RA LV RV Cine Image Pre Contrast Inflammatoryntrast Inflammatory and Imaging Scar Imaging MRI in Pericarditis • Pericardial thickness • Pericardial effusion • Constrictive physiology • Pericardial inflammation COVID and CMR Myocardial Involvement First Author / Yr Patient Cohort Controls Overall LV function Findings Puntmann 2020 100 patients Yes (n=50) Normal 78% abnormal CMR 33% hospitalised / with 60% on going 67% Community inflammation Rajpal S 2020 26 College Athletes No Normal 15% acute myocarditis and 30% prior myocarditis Huang 2020 26 Patients Yes Normal 54% myocardial oedema and 31% LGE. Clark 2021 59 Athletes Yes (athletic and non Normal 3% myocarditis athletic) Kotecha 2021 148 in patients with Yes Normal 27% myocarditis like Trop +Ve injury Daniels 2021 1597 Athletes No Normal 0.31% clinical myocarditis 2.3% if add CMR to work up Joy 2021 149 HCPs Yes Normal No difference between controls and patientsCOVID 19 and CMR Myocarditis – The Challenges • 1) Mindset changes in clinicians and clinician academics • 2) Grossly conflicting literature How to Diagnose Viral Myocarditis? • No criteria for this. • In the past, generally, chest pain (often needing hospital admission), elevated troponin, no flow limiting disease on angiography and then suggestive cardiac MRI. • In Germany, a cardiac biopsy. What then Happens • In follow up of non COVID proven (likely) viral myocarditis in 100 patients at Kings College Hospital, only 2 had on going chest pain 6 months after the original event. • In patients with autoimmune disease and “low level” of myocarditis (small troponin rise and abnormal MRI) it is very rare for patients to have chronic chest pain.What about Pericarditis – ESC Guidelines COVID 19 and CMR – The Challenges • 1) Mindset changes in clinicians and clinician academics • 2) Grossly conflicting literature • 3) Problems with MRI inflammatory techniques in this cohort • Female • Fast heart rates • Assessment of 16 LV segments as focal disease process • STIR artefacts The Patient • 37 yr old female • Heavy chest pain • Referral to me in this scenario would likely be: • Dear Dan, • This lady has a diagnosis of pericarditis or myocarditis on MRI and colchicine hasn’t worked. She didn’t tolerate taking prednisolone. Can we offer something else. My Approach • Start again. • First principles – Hx / examination / bloods / ECG. • Review the MRI scan Beware OMS / OPS Syndromes • Remember of the challenges in inflammatory imaging and use caution when calling subtle changes. • O vercalled O vercalled • M yocarditis P ericarditis • S yndrome S yndrome Red Flags for Myocarditis • Arrhythmia post COVID • Elevated troponin • I have one case of post COVID myocarditis with a chronically mildly elevated troponin… • She has never had chest pain (presentation was with ectopic beats)Red Flags for Pericarditis Conclusions • CMR is a powerful technique for looking at myocardial and pericardial changes. • However, the Post COVID syndrome CMR workup is not easy. • Remember first principles when doing your work up. • OMS and OPS are (in our view) real and can cause patient harm. Danielsado@nhs.net