Coronavirus Disease 2019 and the Athletic Heart

Abstract

and Exercise Cardiology Section generated recommendations to promote safe return to play (RTP) for athletes involved with competitive sports after severe acute respiratory syndrome coronavirus 2 infection. 1 Motivated by observations of cardiac injury in patients hospitalized with coronavirus disease 2019 (COVID-19), 2 that document 1 and others 3-5 proposed algorithms for preparticipation screening, geared toward the detection of COVID-19-associated cardiac complications. At present, the prevalence and clinical implications of COVID-19 cardiac pathology in athletes are unknown. However, publicized media reports of athletes with suspected COVID-19-induced myocarditis, 6,7 coupled with emerging data documenting cardiac injury among community-based cohorts, 8,9 have fueled concerns about the safety of athletics. The definition of an athlete can also be arbitrary. From enthusiasts of youth sports to masters-level exercise (in those aged >35 years), athletes are generally considered individuals who place a high premium on training, competition, and sports achievement. 10 As such, targeted RTP risk stratification for all athletes deserves careful consideration. Relaxation of stay-at-home orders across the US enabled many athletes to return to training and competition. In collaboration with the sports medicine community and despite the current lack of supportive data, we have since accrued considerable experience overseeing RTP testing among athletes with prior COVID-19 infection at all levels of sport. This document was written to address the most common questions posed by the media and in clinics, athletic training rooms, and ongoing discussions among cardiologists who participate in the care of athletes. The authors were selected by the Leadership Council of the Sports and Exercise Cardiology Section of the American College of Cardiology to provide this narrative reassessment of the previous consensus statement. IMPORTANCE Cardiac injury with attendant negative prognostic implications is common among patients hospitalized with coronavirus disease 2019 (COVID-19) infection. Whether cardiac injury, including myocarditis, also occurs with asymptomatic or mild-severity COVID-19 infection is uncertain. There is an ongoing concern about COVID-19-associated cardiac pathology among athletes because myocarditis is an important cause of sudden cardiac death during exercise. OBSERVATIONS Prior to relaxation of stay-at-home orders in the US, the American College of Cardiology's Sports and Exercise Cardiology Section endorsed empirical consensus recommendations advising a conservative return-to-play approach, including cardiac risk stratification, for athletes in competitive sports who have recovered from COVID-19. Emerging observational data coupled with widely publicized reports of athletes in competitive sports with reported COVID-19-associated cardiac pathology suggest that myocardial injury may occur in cases of COVID-19 that are asymptomatic and of mild severity. In the absence of definitive data, there is ongoing uncertai...

Findings from Cardiovascular Evaluation of NCAA Division I Collegiate Student-Athletes after Asymptomatic or Mildly Symptomatic SARS-CoV-2 Infection

“…Two student-athletes with new ECG findings proceeded to cMRI, which showed no evidence of acute or past myocarditis. These data appear to support more recent expert consensus recommendations,[6] suggesting a limited role for cardiovascular testing following asymptomatic or mildly symptomatic SARS-CoV-2 infection among student-athletes. Continued follow-up of athletes with abnormal cardiovascular studies despite normal cMRI is required to understand the implication of these results.…”

“…Eight of the 41 (19.5%) were asymptomatic. No student-athlete had moderate symptoms[6] or required hospitalization.…”

“…[5] Consensus opinions were subsequently revised for the collegiate athlete population, with the recommendation for routine cardiovascular testing after mildly symptomatic infections removed. [6] Multiple other groups have published expert recommendations, but there have been few studies to date validating any of these approaches. [7][8][9][10][11][12][13][14][15] We present a cohort study of 55 collegiate student-athletes with a history of asymptomatic or mildly symptomatic [5] SARS-CoV-2 infection and their subsequent cardiac work-up.…”

“…Eight of the 41 (19.5%) were asymptomatic. No student-athlete had moderate symptoms[6] or required hospitalization.Post-Infection Cardiac ScreeningTwo of the 14 IgG+ student-athletes had an abnormal initial cardiac work-up, both consisting of a normal ECG/troponin and an abnormal echocardiogram (Figure 2); one received an abnormal cardiac diagnosis. This particular student-athlete's echocardiogram showed a mild reduction in LV and moderate reduction in RV function (no prior echo available).…”

COVID-19 and its sequelae: a platform for optimal patient care, discovery and training

“…We recommend persons with COVID-19 and mild symptoms that resolve within 5 days see their primary care provider within 2 weeks of symptom onset (www.cdc.gov). A physical examination, electrocardiogram and other diagnostic tests when indicated and discussion about direct contacts, return to work and return to physical activities are undertaken [6][7][8].…”