Return to sports after COVID-19: cardiologists’ recommendations

Woodruff Health Sciences Center | Nov. 9, 2020

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Janet Christenbury
jmchris@emory.edu

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The prevalence of cardiac injury in athletes who were infected with COVID-19 is still unknown. Newly published guidelines by a group of sports cardiologists provides recommendations on which athletes should undergo more detailed cardiac screening following infection.

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ATLANTA -- In a set of guidelines published in JAMA Cardiology, a group led by sports cardiologists at Emory University School of Medicine and Massachusetts General Hospital (MGH) offers guidance for athletes’ return to play after they have recovered from COVID-19.

Recent reports indicate that COVID-19 may cause heart damage in hospitalized patients with severe infection, but it’s unclear whether cardiac injury also occurs in infected patients who experience only mild symptoms or are asymptomatic. The uncertainty is particularly concerning for athletes because myocarditis—inflammation in the heart usually caused by viral infection—can cause sudden cardiac death during exercise.

“We hope the recommendations put forth in the document will assist practitioners in sports medicine, sports cardiology and general cardiology in the evaluation of athletes for return to play after COVID-19 infection,” says lead author Jonathan Kim, MD, MSc, chief of Sports Cardiology at Emory University School of Medicine. “These recommendations are intended to guide the process of determining who requires more detailed cardiac screening and ensure that all athletes post-COVID-19 infection should have a slow and gradual return to training with close monitoring of persistent symptoms, regardless of the severity of infection.”

The paper is designed to address common questions posed by coaches and physicians who care for athletes. Considering evolving data, it represents a reassessment of a previous consensus statement by the American College of Cardiology, co-authored by Kim and published in May.

The paper contains flowcharts for high school athletes, adults in competitive sports, and recreational masters athletes (age 35 and up), and recommendations for how diagnostic tests such as cardiac MRI (magnetic resonance imaging), echocardiography and high-sensitivity cardiac troponin should be used.

“The safety of sports was really the impetus behind this document. But what we have seen is that not all COVID-19 is created equal,” says senior author Aaron Baggish, MD, director of the Cardiovascular Performance Program at MGH. “There is still a need to gather more data in order to study the effects of this virus, but my colleagues and I have seen athletes who have been either mildly ill or asymptomatic who have returned to activity without any clinically relevant evidence of cardiovascular injury.”

Kim, Baggish and colleagues have observed that athletes infected with COVID-19 who experienced no or mild symptoms did not exhibit signs of heart injury. For such athletes, they do not recommend detailed cardiac screening. The prevalence of cardiac injury in athletes who were infected with COVID-19 is still unknown, however, and the authors believe it is prudent to screen for heart damage in athletes with moderate to severe symptoms.

For those who experienced moderate to severe symptoms, screening should begin with electrocardiogram, cardiac ultrasound or high-sensitivity cardiac troponin; if those have abnormal test results, cardiac MRI can be considered, the experts say. High-sensitivity cardiac troponin should be performed with a 24-48 hour delay after strenuous exercise, because the stress of exercise can detect abnormalities in healthy individuals.

Despite recent small studies showing that cardiac magnetic resonance imaging has detected potential abnormalities in individuals who have recovered from COVID-19, current evidence doesn’t justify its use as a universal screening tool for athletes, the group says.

The paper’s other authors were Benjamin D. Levine, MD, of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Dallas and The University of Texas Southwestern Medical Center; Dermot Phelan, MD, PhD, of the Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina; Michael S. Emery, MD, MS, of the Sports Cardiology Center, Department of Cardiovascular Medicine, Cleveland Clinic; Mathew W. Martinez, MD, of Morristown Medical Center, Atlantic Health System, Morristown, New Jersey; Eugene H. Chung, MD, MSc, of Michigan Medicine at the University of Michigan, Ann Arbor; and Paul D. Thompson, MD of Hartford Hospital in Connecticut.