SARS-CoV-2 infection and return-to-play in junior competitive athletes: is systematic cardiac screening needed?

Abstract

Funding Acknowledgements Type of funding sources: None. Background SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents that are less susceptible to adverse clinical outcomes and are often asymptomatic. Purpose We conducted this prospective multi-centre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return-to-play. Methods Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting electrocardiogram (ECG), echocardiogram, and exercise ECG testing. Further investigations were performed in cases of abnormal findings. Results A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%), and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation were found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return-to-play was achieved after complete clinical resolution. Conclusions The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms, ECG abnormalities and arrhythmias at rest and/or during exercise should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes.

Short and mid‐term characteristics of COVID‐19 disease course in athletes: A high‐volume, single‐center study

“…They concluded that echocardiography should be reserved for those with cardiopulmonary symptoms or ECG abnormalities. 16 Initial findings at our center suggested no evident signs of myocardial involvement on CMR examination in twelve elite athletes who recovered from COVID-19. 17 By broadening our research to 147 subjects, definite signs of myocarditis were as scarcely prevalent as 1.4% in the whole cohort.…”

“…Cavigli et al have recently reported their experiences with junior competitive athletes wherein a cohort of 571 subjects found that half of the athletes had had only mild symptoms and pericardial involvement was rare, examined by transthoracic echocardiography. They concluded that echocardiography should be reserved for those with cardiopulmonary symptoms or ECG abnormalities 16 …”

Coronavirus disease 2019 and the young heart: prevention, treatment, and return to play

“…Among 1597 collegiate athletes in the Big Ten COVID-19 Cardiac Registry, the prevalence of clinical myocarditis with a symptombased screening strategy was 0.3%, whereas the use of MRI increased the prevalence of all (both clinical and subclinical) myocarditis to 2.3% [24]. Other studies have shown similar results, reporting a 0.7-3.3% prevalence of myocarditis or pericarditis following COVID-19 infection, with results varying based on the evaluation strategy [ There are few reports evaluating the prevalence of COVID-19-related cardiac disease in younger patients, though some suggest a similar prevalence to that seen in older patients [26].…”

“…Although these numbers are far lower than those initially reported, they suggest a measurable risk of COVID-19-related cardiac disease following apparent recovery from acute COVID-19. There are few reports evaluating the prevalence of COVID-19-related cardiac disease in younger patients, though some suggest a similar prevalence to that seen in older patients [26].…”

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 1: acute respiratory infections

“…(62,(133)(134)(135)(136)(137)(138) These "expert opinions" were initially based on no data to support the guidelines, but recently some data has become available. (139)(140)(141) The more recent guidelines were only for athletes with SARS-CoV-2 infection and did not focus on all ARinf (irrespective of the pathogen responsible for the ARinf). They have not consistently considered the key concepts and the 3 steps in the RTS decision making process, as discussed above.…”