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Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play
Jonathan H Kim1, Benjamin D Levine2,3, Dermot Phelan4
1Emory University School of Medicine, Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia.
Insights
Cardiac injury is common in hospitalized COVID-19 patients. Uncertainty remains regarding cardiac pathology in athletes with mild or asymptomatic coronavirus disease 2019 (COVID-19), impacting return-to-play decisions.
Area of Science:
- Sports cardiology
- Infectious disease
- Cardiovascular pathology
Background:
- Cardiac injury is frequent in hospitalized COVID-19 patients, with negative prognostic implications.
- The occurrence of cardiac injury, including myocarditis, in asymptomatic or mild COVID-19 cases, particularly in athletes, remains uncertain.
- Myocarditis is a significant cause of sudden cardiac death during exercise, raising concerns for athletes recovering from COVID-19.
Purpose of the Study:
- To address common questions about COVID-19 and cardiac pathology in competitive athletes.
- To extend return-to-play considerations to specific athlete populations not previously covered.
- To provide guidance amidst uncertainty regarding cardiovascular risk stratification for athletes post-COVID-19.
Main Methods:
- Review of emerging observational data and clinical experiences.
- Analysis of early experiences in the clinical oversight of athletes following COVID-19 infection.
- Anticipation of multicenter registry data on cardiovascular outcomes in athletes post-COVID-19.
Main Results:
- Observational data suggest myocardial injury may occur in asymptomatic and mild COVID-19 cases.
- There is ongoing uncertainty regarding the optimal cardiovascular risk stratification for athletes after COVID-19.
- Early clinical experiences highlight key areas of uncertainty for practitioners.
Conclusions:
- Cardiac pathology in athletes after COVID-19 requires careful consideration for safe return-to-play.
- Further data are needed to establish definitive guidelines for cardiovascular risk stratification.
- Cardiology and sports medicine practitioners must navigate current uncertainties in managing athletes post-COVID-19.
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 uncertainty about the optimal approach to cardiovascular risk stratification of athletes in competitive sports following COVID-19 infection.
Conclusions And Relevance:
This report was designed to address the most common questions regarding COVID-19 and cardiac pathology in athletes in competitive sports, including the extension of return-to-play considerations to discrete populations of athletes not addressed in prior recommendations. Multicenter registry data documenting cardiovascular outcomes among athletes in competitive sports who have recovered from COVID-19 are currently being collected to determine the prevalence, severity, and clinical relevance of COVID-19-associated cardiac pathology and efficacy of targeted cardiovascular risk stratification. While we await these critical data, early experiences in the clinical oversight of athletes following COVID-19 infection provide an opportunity to address key areas of uncertainty relevant to cardiology and sports medicine practitioners.
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