COVID-19: the Risk to Athletes

Abstract

Purpose of Review The COVID-19 pandemic has had a profound impact on athletics, and the question of safely resuming competitive sports at all levels has been a source of significant debate. Concerns regarding myocarditis and the risk of arrhythmias and sudden death in athletes have prompted heightened attention to the role of cardiovascular screening. In this review, we aim to comprehensively outline the cardiovascular manifestations associated with COVID-19 infection, to discuss screening, diagnosis, and treatment strategies, and to evaluate the current literature on the risk to athletes and recommendations regarding return-to-play. Recent Findings COVID-19 is known to cause myocarditis, with presentations ranging from subclinical current or prior infection detected on cardiac MRI imaging, to fulminant heart failure and shock. While initial data early in the pandemic suggested that the risk of myocarditis could be significant even in patients with nonsevere COVID-19 infection, recent studies suggest a very low prevalence of clinically significant disease in young athletes. Summary While COVID-19 can have significant cardiovascular manifestations, recent data demonstrate that a screening approach guided by severity of COVID-19 infection and cardiovascular symptoms allows the majority of athletes to safely return to play in a timely manner. We must continue to tailor our approach to screening athletes as knowledge grows, and further research on the longitudinal cardiovascular effects of COVID-19 is needed.

Cardiac Changes Related to COVID-19 in Athletes: A Brief Review

“…In COVID-19 patients, the mechanism of myocardial injury has several etiologies, such as direct viral infection via binding of the angiotensin-converting enzyme 2 (ACE2) receptors on myocardial and endothelial surfaces, virus-induced immune reaction that releases too many cytokines into the blood quickly (cytokine storm) leading to ischemia and necrosis. Vessel inflammation and a hypercoagulable state can also contribute to ischemia and thrombotic complications [ 2 , 9 ]. Increase on cardiac biomarkers, such as troponin-I and B-type natriuretic peptide (BNP), are common in more severe cases, as are markers of systemic inflammation, including C-reactive protein (CRP) [ 10 ].…”

“…It is known that COVID-19 affects mainly the respiratory tract and has a clinical characteristic from a mild flulike illness to potentially lethal acute respiratory syndrome or pneumonia [ 1 ]. However, it is also associated with several cardiovascular complications, specific arrhythmias, myocardial injury, and other cardiovascular disease, with potentially fatal cardiovascular events in athletes and non-athletes [ 2 ].…”

“…Previous data suggest that athletes are susceptible to cardiovascular complications after COVID-19 infection, including myocarditis, pre-myocardial injury, increased arterial stiffness, and decreased vascular function [ 2 , 3 ], raising concern about myocardial inflammation as an additional cause of cardiac damage from COVID-19 in this population [ 4 , 5 ]. In order to face the COVID-19 spread and prevent the collapse of the health system, some rigorous strategies based on social distancing and adherence to home quarantine have been practiced worldwide.…”

“…Strategies to contain the spread of the virus have included cancellation of sporting events and seasons from amateur to professional levels. Impacting the physical activity levels, cardiorespiratory fitness, and physical performance in athletes [ 2 ].…”

“…However, several recommendations have been proposed in order to minimize the increased risk for malignant arrhythmias among athletes exposed to COVID-19, during this return to sport phase [ 6 ••]. There are still several clinical challenges in dealing with COVID-19–related cardiac changes in athletes, such as who to screen; how to screen; how to interpret the clinical tests; the prevalence of COVID-19 cardiac involvement; the screen test sensitivity and specificity in order to detect myocardial pathology; and return to sport and training safety [ 2 , 6 ••]. Therefore, this study aims to describe and revise the main cardiac alterations related to COVID-19 in elite and recreational athletes, as well as current recommendations for clinical screening, and safe return to sports routine.…”