Cardiac involvement in consecutive elite athletes recovered from Covid‐19: A magnetic resonance study

Abstract

Magnetic resonance (MR) studies suggested cardiac involvement post‐Covid‐19 in a significant subset of affected individuals, including athletes. This brings serious clinical concerns regarding the potential need for in‐depth cardiac screening in athletes after Covid‐19 before return to play. The aim of this study was to gain further insight into the relation between Covid‐19 and cardiac involvement in professional athletes. This was a retrospective cohort study, in which 26 consecutive elite athletes (national team, Olympians, top national league players; median age 24 years, interquartile range [IQR] 21–27, 81% female) were included. At 1.5 T including balanced steady‐state free precession cine imaging, T1 and T2‐mapping using Myomaps software (Siemens), dark‐blood T2‐weighted images with fat suppression, and late gadolinium enhancement (LGE) with phase‐sensitive inversion recovery sequence were used. The athletes had mainly asymptomatic or mild course of the disease (77%). They were scanned after a median of 32 days (IQR 22–62 days) from the diagnosis. MR data were reviewed by three independent observers, each with >10 years cardiac MR experience. Native T1, T2, extracellular volume, and T2 signal intensity ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Statistical analyses used were Pearson correlation and Bland–Altman repeatability analysis. At the time of MR the athletes had no pathologic electrocardiogram abnormalities or elevated troponin levels. MR did not reveal any case of acute myocarditis. Cardiac abnormalities were found in five (19%) athletes, including four athletes presenting borderline signs of isolated myocardial edema and one athlete showing nonischemic LGE with pleural and pericardial effusion. Another athlete had signs of persistent lung congestion without cardiac involvement. We have shown that in a small group of elite athletes with mainly asymptomatic to mild Covid‐19, lack of electrocardiographic changes, and normal troponin concentration 1–2 months after the diagnosis, there were no signs of acute myocarditis, but 19% of athletes had some abnormalities as assessed by cardiac MR. Level of Evidence 4 Technical Efficacy Stage 3

Cardiac sequelae after coronavirus disease 2019 recovery: a systematic review

“…Through screening of titles and abstracts, we excluded 2670 records, leaving 197 to be assessed as full text. Of these, we finally included in this review 35 studies ( 5 , 8 , 11 , 12 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ), of which 3 were pre-prints ( 5 , 23 , 50 ), three were presented as research letters ( 21 , 43 , 51 ) and three were presented as research communications ( 22 , 31 , 44 ). The reasons for excluding 162 articles are listed in the PRISMA flow chart (see Figure 1 ) ( 52 ).…”

“…Of the 35 studies included in this review, 15 were prospective cohort ( 8 , 12 , 22 , 29 , 30 , 31 , 34 , 35 , 40 , 41 , 42 , 44 , 45 , 47 , 50 ), 7 were case reports ( 21 , 25 , 28 , 36 , 37 , 39 , 48 ), 5 had a cross-sectional design ( 5 , 20 , 24 , 26 , 38 ), 4 were case series ( 23 , 32 , 43 , 46 ), 3 were retrospective cohort ( 11 , 27 , 49 ), and 1 was ambidirectional cohort study ( 33 ).…”

“…22 articles (63%) included patients previously hospitalized for COVID-19 (N=51117, 97.2%) ( 11 , 21 , 24 , 25 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 49 ), 8 studies a mixed population of discharged patients and outpatients (N= 1330, 2.5%) ( 5 , 8 , 12 , 22 , 26 , 29 , 47 , 50 ) among which one included healthcare workers ( 5 ), 5 included only outpatients (N=122; 0.3%) ( 20 , 23 , 27 , 28 , 30 ), among which 4 included solely athletes ( 20 , 23 , 27 , 30 ).…”

Return to Play for Athletes After COVID-19 Infection

“…Total Rajpal et al 2 Vago et al 4 Małek et al 5 Starekova et al 6 Clark et al 7 Martinez et al 8 Moulson et al 9 Hendrickson et al 10 Hence, the rapid evolution of data in this area continues to support the idea that the more practical and more widely available approach of testing with ECG, echocardiography, and serum troponin likely improves specificity and decreases burden of potentially unwarranted athletic restriction. The data in the article by Daniels et al 11 elevate our ability to intelligently discuss the issues with athletes, their families, coaches, performance coaches, trainers, sports scientists, and institutions, among the many stakeholders involved in the well-being of athletes within the universe of organized sports.…”

“…Both the Kim et al report 1 and our Editorial 3 at the time called for larger data sets, so that recommendations could be refined and more informed by data.In only 6 months since then, there has been a remarkable amount of information acquired, analyzed, and published regarding post-COVID-19 prevalence of cardiac abnormalities in athletes, as summarized in the Table. 2,[4][5][6][7][8][9][10][11] In a recent study of 789 professional athletes, screening consisted of serum troponin testing, ECG, and echocardiography, regardless of symptoms. 8 Thirty of these athletes (3.8%) had abnormal test results resulting in referral for CMR imaging, with 3 diagnosed with myocarditis.…”