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ObjectiveLongitudinal consequences and potential interactions of COVID-19 and elite-level sports and exercise are unclear. Therefore, we determined the long-term detrimental cardiac effects of the interaction between SARS-CoV-2 infection and the highest level of sports and exercise.MethodsThis prospective controlled study included elite athletes from the Evaluation of Lifetime participation in Intensive Top-level sports and Exercise cohort. Athletes infected with SARS-CoV-2were offered structured, additional cardiovascular screenings, including cardiovascular MRI (CMR). We compared ventricular volumes and function, late gadolinium enhancement (LGE) and T1 relaxation times, between infected and non-infected elite athletes, and collected follow-up data on cardiac adverse events, ventricular arrhythmia burden and the cessation of sports careers.ResultsWe included 259 elite athletes (mean age 26±5 years; 40% women), of whom 123 were infected (9% cardiovascular symptoms) and 136 were controls. We found no differences in function and volumetric CMR parameters. Four infected athletes (3%) demonstrated LGE (one reversible), compared with none of the controls. During the 26.7 (±5.8) months follow-up, all four athletes resumed elite-level sports, without an increase in ventricular arrhythmias or adverse cardiac remodelling. None of the infected athletes reported new cardiac symptoms or events. The majority (n=118; 96%) still participated in elite-level sports; no sports careers were terminated due to SARS-CoV-2.ConclusionsThis prospective study demonstrates the safety of resuming elite-level sports after SARS-CoV-2 infection. The medium-term risks associated with SARS-CoV-2 infection and elite-level sports appear low, as the resumption of elite sports did not lead to detrimental cardiac effects or increases in clinical events, even in the four elite athletes with SARS-CoV-2 associated myocardial involvement.

Background: Cardiac thrombi are a major risk factor for ischemic stroke, but are rarely diagnosed in the acute phase. We examined characteristics and functional outcome of patients with ischemic stroke and a concomitant cardiac thrombus detected on cardiac CT performed in the acute phase.Patients and Methods: We used data from “Mind the Heart,” a prospective cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during their acute stroke imaging protocol. We compared characteristics, functional outcome (modified Rankin scale) and stroke recurrence rate at 90 days of patients with a cardiac thrombus on CT (defined as filling defect <100 Hounsfield Units) to those without a cardiac thrombus.Results: Among 452 included patients, cardiac CT detected 41 thrombi in 38 (8%) patients. Thrombi were most often located in the left atrial appendage (31/38 [82%]). Patients with a cardiac thrombus more frequently had intracranial occlusions in multiple vascular territories (5% vs 0.5%, p= 0.04) and a higher baseline NIHSS score (17 [IQR 6–22] vs 5 [IQR 2–3], p< 0.001) compared to patients without a cardiac thrombus. In 13/38 (34%) patients with a cardiac thrombus, no atrial fibrillation was detected. A cardiac thrombus was associated with worse functional outcome (adjusted common odds ratio 3.18 95%CI 1.68–6.00). Recurrence rate was not significantly different (8% vs 4%, aOR 1.50 (0.39–5.82).Discussion and Conclusion: Cardiac CT detected a cardiac thrombus in one in every 12 patients with acute ischemic stroke, and these patients had more severe deficits, multivessel occlusions, and a worse functional outcome.

Background:Cardiac CT acquired during the acute stroke imaging protocol is an emerging alternative to transthoracic echocardiography (TTE) to screen for sources of cardioembolism, but its diagnostic accuracy to detect patent foramen ovale (PFO) is unclear.Methods:This was a substudy of Mind the Heart, a prospective single-center cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent routine work-up, including TTE. We included patients <60 years who underwent TTE with agitated saline contrast (cTTE). Presence of a PFO on CT and cTTE was scored according to predefined criteria by a cardioradiologist and cardiologist, respectively, who were blinded to each other’s scoring. On CT, PFO was defined as a crypt shaped contrast jet from the left atrium to the right atrium towards the vena cava or an atrium septum discontinuity. On cTTE, a PFO was defined as the appearance of microbubbles in the left atrium within 3-6 cardiac beats after opacification of the right atrium. We assessed the sensitivity and specificity of cardiac CT for the detection of PFO using cTTE as the reference standard.Results:Of 452 patients in Mind the Heart, 92 were younger than 60 years. Of these, 56 (61%) patients underwent both cardiac CT and cTTE and were included. Median age was 55 (interquartile range [IQR] 49-57) years and 38 (68%) were male. In total, 32/56 (57%) patients had cryptogenic stroke and their median Risk of Paradoxical Embolism score was 6 (IQR 6-7). Cardiac CT detected a PFO in 5/56 (9%) patients, 3 of which were confirmed on cTTE. cTTE detected a PFO in 12/56 (21%) patients. The sensitivity and specificity of cardiac CT were 25% (95%CI: 5-57%) and 95% (95%CI: 85-99%), respectively. Positive and negative predictive value were 59% (95%CI: 22-87) and 83% (95%CI: 77-87), respectivelyConclusion:Due to its low sensitivity, prospective ECG-gated cardiac CT does not appear to be a suitable screening method for PFO. If cardiac CT is used to screen for cardioembolism, additional echocardiography remains indicated in patients with cryptogenic stroke in whom PFO detection would have therapeutic consequences.

The aim of this study was to identify patients in whom the clinical diagnosis of diverticulitis can be made with a high certainty, distinguishing them from patients requiring imaging.

Background:Cardiac thrombi are a major risk factor for ischemic stroke. We used cardiac CT to assess the prevalence of cardiac thrombi in acute ischemic stroke patients.Methods:This was a substudy of Mind the Heart, a prospective single-center cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent routine stroke work-up, including transthoracic echocardiography (TTE). Patients were included from May 2018 to November 2020. We compared patients with a cardiac thrombus on CT (defined as filling defect <100 Hounsfield’s Units) to those without a cardiac thrombus. Outcomes were functional outcome on the modified Rankin scale (mRS) and ischemic stroke recurrence at 90 days.Results:Of 452 included patients, cardiac CT detected 40 thrombi in 38 (8%) patients. Thrombi were located in the left atrial appendage in 31 (7%), left atrium in 2 (0.4%) and left ventricle in 7 (2%) patients. TTE, performed in 25 patients with a cardiac thrombus (median time CT to TTE 1 day), detected a thrombus in 2 patients (0.4%, both left ventricle thrombi). Patients with a cardiac thrombus more frequently had a history of atrial fibrillation (40% vs 15%), used anticoagulation (42% vs 16%), had a large vessel occlusion (58% vs 41%), had intracranial occlusions in multiple vascular territories (5% vs 0.5%) and had a higher baseline NIHSS (17 [IQR 6-22] vs 5 [IQR 2-3]). In total, 26/38 (68%) patients with a cardiac thrombus had a history of atrial fibrillation or had atrial fibrillation diagnosed during stroke work-up. At 90 days, 19/23 (83%) patients with a cardiac thrombus who were alive were treated with anticoagulation. Patients with a cardiac thrombus had worse functional outcome (median mRS 4 [IQR 2-6] vs 2 [IQR 1-4], p<0.01) and non-significantly more often had a recurrent ischemic stroke (8% vs 5%,p=0.61) than patients without a cardiac thrombus.Conclusion:Cardiac CT detected a cardiac thrombus in 1 in every 12 patients with acute ischemic stroke. These thrombi were rarely detected with TTE. Patients with cardiac thrombi more often had atrial fibrillation and severe neurological deficits. Functional outcome was worse in patients with cardiac thrombi.

OBJECTIVE: To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain. Design Fully paired multicentre diagnostic accuracy study with prospective data collection. Setting Emergency departments of two university hospitals and four large teaching hospitals in the Netherlands. Participants 1021 patients with non-traumatic abdominal pain of >2 hours’ and <5 days’ duration. Exclusion criteria were discharge from the emergency department with no imaging considered warranted by the treating physician, pregnancy, and haemorrhagic shock. Intervention All patients had plain radiographs (upright chest and supine abdominal), ultrasonography, and computed tomography (CT) after clinical and laboratory examination. A panel of experienced physicians assigned a final diagnosis after six months and classified the condition as urgent or non-urgent. MAIN OUTCOME MEASURES: Sensitivity and specificity for urgent conditions, percentage of missed cases and false positives, and exposure to radiation for single imaging strategies, conditional imaging strategies (CT after initial ultrasonography), and strategies driven by body mass index and age or by location of pain. RESULTS: 661 (65%) patients had a final diagnosis classified as urgent. The initial clinical diagnosis resulted in many false positive urgent diagnoses, which were significantly reduced after ultrasonography or CT. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% (95% confidence interval 87% to 92%) for CT and 70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% (46% to 52%) of patients would have CT. Alternative strategies guided by body mass index, age, or location of the pain would all result in a loss of sensitivity. CONCLUSION: Although CT is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, using ultrasonography first and CT only in those with negative or inconclusive ultrasonography results in the best sensitivity and lowers exposure to radiation.