ObjectivesQuantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports.DesignSystematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes.Data sourcesCombinations of key terms in Medline, Embase and Scopus (through 2 June 2021).Eligibility criteria for selecting studiesInclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age <18 or >64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists.ResultsIn total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%–15%, pericardial effusion 0%–58% and late gadolinium enhancement (LGE) 0%–46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%–4%) versus low scores (38%–42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities.Summary/conclusionAthletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03139968.

Background COVID-19 has been associated with myocardial abnormalities on cardiac magnetic resonance imaging (CMR). We report a case of COVID-19 myocarditis in an elite athlete. Case Summary A male, 21-year-old elite football player had tested positive for SARS-CoV-2 on a polymerase-chain-reaction test and was referred for cardiac evaluation after experiencing palpitations after returning to sports (RTS). Biochemical evaluation demonstrated elevated NT-proBNP and high-sensitive Troponin T (hsTNT). Echocardiography demonstrated LV function within normal ranges for athletes but with diminished basal, posterolateral, and septal strain. CMR showed increased T1 values and late gadolinium enhancement (LGE) in the basolateral and mid-ventricular posterior segments. Focal COVID-19 myocarditis was diagnosed and the patient remained restricted from sports, in line with the 2020 ESC sports cardiology guidelines. Two months later his electrocardiogram showed inferoposterolateral T-wave inversion. Serial imaging studies were performed to optimise RTS timing. CMR showed persistently increased T1/T2 values and persistent LGE at five and seven months. At nine months, FDG-PET-CT demonstrated no pathologically increased cardiac FDG-uptake. Subsequent exercise ECGs and Holters demonstrated no complex ventricular arrhythmias. The patient made a complete return to elite competitive sports, without any adverse events at fifteen months of follow-up. Discussion Cardiac symptoms in athletes post-COVID-19 should prompt cardiac evaluation. As COVID-19 myocarditis inflammation can persist beyond the three to six months of recommended sports restriction, a more personalised approach to RTS timing can be warranted. In cases with myocardial oedema without other signs of inflammation, FDG-PET-CT can be of added value to assess active myocardial inflammation.

Background and aimThe efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection.MethodsIn this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes.Results511 soccer players (median age 21 years, IQR 18–26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3–10) compared with athletes without de-novo ECG changes (2 days, IQR 1–3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%.Conclusions3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.