Myocarditis in Athletes Recovering from COVID-19: A Systematic Review and Meta-Analysis

Modica, Gloria; Bianco, Massimiliano; Sollazzo, Fabrizio; Murro, Emanuela Di; Monti, Riccardo; Cammarano, Michela; Morra, Lorenzo; Nifosì, Francesco Maria; Gervasi, Salvatore Francesco; Gravina, Ester Manes; Zeppilli, Paolo; Palmieri, Vincenzo

doi:10.3390/ijerph19074279

Cited by 31 publications

(31 citation statements)

References 56 publications

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“…In accordance, a study of children who recently recovered from mildly symptomatic COVID-19 infections showed no evidence of myocardial inflammation, fibrosis, or functional cardiac impairment on CMR [ 27 ]. Furthermore, the rate in young athletes was also lower than those previously reported in an older population [ 28 ]. Hence, these results are reassuring, however, do not rule out cardiac involvement in ACHD patients with more severe symptoms of COVID-19 requiring hospitalization or treatment in the intensive care unit.…”

Section: Discussioncontrasting

confidence: 60%

COVID-19 Infections in Adults with Congenital Heart Disease—A Prospective Single-Center Study in an Outpatient Setting

Langes

Meierhofer²,

Nagdyman³

et al. 2022

JCM

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Background: COVID-19 might pose a risk for adults with congenital heart disease (ACHD). However, data regarding the rate of infection as well as myocardial involvement in ACHD patients are currently lacking. Methods: During the study period from January to June 2021, all consecutive outpatients from our ACHD clinic were eligible to participate. Clinical data were collected. An antibody test for COVID-19 was performed in all patients. Cardiovascular magnetic resonance imaging (CMR) was offered to those with a positive antibody test. Results: Overall, 420 patients (44.8% female, mean age 36.4 ± 11.6 years) participated. Congenital heart defect (CHD) complexity was simple in 96 (22.9%), moderate in 186 (44.3%), complex in 117 (27.9%), and miscellaneous in 21 (5.0%) patients. Altogether, 28 (6.7%) patients had a positive antibody test. Out of these, 14 had an asymptomatic course. The others had mainly mild symptoms and were managed as outpatients. Furthermore, 11 patients (39.3%) had even not been aware of their infection. Fourteen patients underwent a CMR without signs of myocardial involvement in any of them. Conclusions: We observed a number of undetected cases of COVID-19 infections in our ACHD population. Reassuringly, in all cases, the infection had a mild clinical course.

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Section: Discussioncontrasting

confidence: 60%

COVID-19 Infections in Adults with Congenital Heart Disease—A Prospective Single-Center Study in an Outpatient Setting

Langes

Meierhofer²,

Nagdyman³

et al. 2022

JCM

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“…Conflicting results have been reported over the last months regarding the prevalence of CMR findings (from 0.4 up to 15%) suggestive for myocardial involvement in competitive athletes during the recovery after even an asymptomatic or mildly symptomatic SARS-CoV-2 infection [ 1 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ]. A recent metanalysis estimated a pooled prevalence of COVID-19-related myocarditis among athletes, ranging from 1 to 4% [ 25 ]. However, given the cross-sectional nature of the previous study designs, with different times of evaluation and protocol applied, and different criteria for recruiting athlete cohorts, uncertainty still exists regarding how to advise a safe return-to-play in competitive athletes.…”

Section: Discussionmentioning

confidence: 99%

Systematic Cardiovascular Screening in Olympic Athletes before and after SARS-CoV-2 Infection

Maestrini

Filomena

Birtolo

et al. 2022

JCM

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Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in athletes. The aim of this study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program. Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior to RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-h ECG monitoring, and spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation. Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, and 4% had pneumonia. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes; however, only 6% (n = 3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR. Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority, and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in the presence of symptoms and elevated biomarkers). Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears unjustified.

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“…However, multiple factors might have contributed to our findings. First, the majority of adverse events occurred in the arrhythmic group, which is already known for being associated with worse outcomes [ 6 , 7 , 25 ]. Second, a non-trivial subset of patients with abnormal EST (7 of 35, 20%) received a diagnosis of active myocarditis following the subsequent disease restaging: this observation suggests that adverse prognostic significance may be carried out by active myocardial inflammation, as previously reported [ 34 ].…”

Section: Discussionmentioning

confidence: 99%

“…Consistently, international guideline documents agree in recommending the use of EST after six months from acute myocarditis before resuming competitive sport participation [ 4 , 5 ]. In this setting, the absence of arrhythmia and ischemia signs is needed to demonstrate safety during incremental physical activity [ 6 ]. Remarkably, the evidence currently supporting the role of EST in myocarditis focuses on the classic acute coronary syndrome (ACS)-like presentation of myocarditis, which is the most common and benign scenario [ 7 , 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

Exercise Stress Test Late after Arrhythmic versus Nonarrhythmic Presentation of Myocarditis

Peretto

Gulletta

Slavich

et al. 2022

JPM

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Background. Exercise stress test (EST) has been scarcely investigated in patients with arrhythmic myocarditis. Objectives. To report the results of EST late after myocarditis with arrhythmic vs. nonarrhythmic presentation. Methods. We enrolled consecutive adult patients with EST performed at least six months after acute myocarditis was diagnosed using gold-standard techniques. Patients with ventricular arrhythmia (VA) at presentation were compared with the nonarrhythmic group. Adverse events occurring during follow-up after EST included cardiac death, disease-related rehospitalization, malignant VA, and proven active myocarditis. Results. The study cohort was composed of 128 patients (age 41 ± 9 y, 70% males) undergoing EST after myocarditis. Of them, 64 (50%) had arrhythmic presentation. EST was performed after 15 ± 4 months from initial diagnosis, and was conducted on betablockers in 75 cases (59%). During EST, VA were more common in the arrhythmic group (43 vs. 4, p < 0.001), whereas signs and symptoms of ischemia were more prevalent in the nonarrhythmic one (6 vs. 1, p = 0.115). By 58-month mean follow-up, 52 patients (41%) experienced adverse events, with a greater prevalence among arrhythmic patients (39 vs. 13, p < 0.001). As documented both in the arrhythmic and nonarrhythmic subgroups, patients had greater prevalence of adverse events following a positive EST (40/54 vs. 12/74 with negative EST, p < 0.001). Electrocardiographic features of VA during EST correlated with the subsequent inflammatory restaging of myocarditis. Nonarrhythmic patients with uneventful EST both on- and off-treatment were free from subsequent adverse events. Conclusions. Late after the arrhythmic presentation of myocarditis, EST was frequently associated with recurrent VA. In both arrhythmic and nonarrhythmic myocarditis, EST abnormalities correlated with subsequent adverse outcomes.

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Myocarditis in Athletes Recovering from COVID-19: A Systematic Review and Meta-Analysis

Cited by 31 publications

References 56 publications

COVID-19 Infections in Adults with Congenital Heart Disease—A Prospective Single-Center Study in an Outpatient Setting

COVID-19 Infections in Adults with Congenital Heart Disease—A Prospective Single-Center Study in an Outpatient Setting

Systematic Cardiovascular Screening in Olympic Athletes before and after SARS-CoV-2 Infection

Exercise Stress Test Late after Arrhythmic versus Nonarrhythmic Presentation of Myocarditis

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