Myocarditis in Athletes: Risk Factors and Relationship with Strenuous Exercise

Amidst the SARS-CoV-2 pandemic, myocarditis in athletes has demanded increased attention primarily because of the risk of sudden cardiac death. While most athletes who experience myocardial inflammation recover, extensive measures for screening and diagnosis are taken because of the possibility of cardiac necrosis, fibrosis, and remodeling. Several risk factors have been identified that may contribute to the development of this inflammatory response, predominantly a history of viral or bacterial upper-respiratory infections. Recent research suggests new risks specific to athletes remain in question, such as the intensity and longevity of sustained exercise, vaccination status, and genetic and epidemiologic factors. Electrocardiography, echocardiography, and cardiac magnetic resonance imaging are commonly utilized for the diagnosis of myocarditis; however, reference standards are lacking because of the variety of clinical presentations. In this article, we discuss the epidemiology, pathophysiology, and presentation of myocarditis in athletes. We then review the available literature to provide a deeper insight into the diagnostic testing methods available, with the aim of outlining the efficacy and prognostic value. Next, we discuss an algorithmic approach to patient care and treatment based upon hemodynamic stability, symptoms, and findings on testing. Finally, this article reviews the current return to play guidelines and the rationale for revisions to return-to-play protocols.