Expert Opinion: Return to Play and COVID-19 ... Just Getting Started

On March 11th, 2020, just prior to the tip of the Utah Jazz™ versus Oklahoma City Thunder™, the National Basketball Association™ season was abruptly halted in dramatic fashion after it was disclosed a member of the Jazz™ tested positive for the SARS-2-Coronavirus (COVID-19). In subsequent and rapid fashion, iconic American sporting events, including March Madness™, The Masters™, and Major League Baseball™ Opening Day, were all cancelled or postponed. Across the national landscape, sports were appropriately shut down as the pandemic spread throughout the United States.

While the resumption of competitive sport in the United States ultimately depends on public health policy, it is evident that the cardiovascular management of athletes recovering from COVID-19, including return-to-play, poses numerous and significant challenges. Unfortunately, essential questions currently lack evidenced-based answers. For example, what is the prevalence of asymptomatic COVID-19 infection in the community? What is the prevalence of cardiac injury associated with asymptomatic or mild cases of non-hospitalized COVID-19? Taking into account all of these uncertainties and the high stakes of ensuring the cardiac health of our athletes on the field, apprehension and numerous concerns have been expressed by athletic trainers, team officials, and sports organizations. While acknowledging the need for robust data to efficiently guide the return-to-play process, we understand there is also a need for preliminary recommendations for the previously infected COVID-19 athlete.

With this in mind, leaders within the American College of Cardiology's Sports & Exercise Cardiology Section and sports cardiology experts around the country recently developed an expert consensus clinical framework designed to assist practitioners through return-to-play considerations.1 These opinion-based recommendations are primarily based on the temporal progression of infection and potential for cardiovascular involvement based on the degree of symptoms. In particular, for now, these recommendations emphasize exercise restrictions during documented COVID-19 infection, in combination with a more conservative cardiac risk stratification process as symptoms worsen. Importantly, the recommendations acknowledge current limitations and critical uncertainties. And perhaps most essential, it is understood that as rigorous data are obtained, recommendations are clearly subject to change and will likely evolve.

The ripple effects stemming from COVID-19 will impact all aspects of healthcare, likely for years to come. For sports medicine practitioners and sports cardiologists, COVID-19 has forced us to reconsider our algorithmic approach to the pre-participation cardiac evaluation, the symptomatic athlete, and return-to-play. With the sobering realization that COVID-19 is here for the foreseeable future, we must proceed carefully, balancing the potential cardiovascular concerns associated with COVID-19 with clinical equipoise. At present, as we continue to seek appropriate COVID-19 clinical strategies, we understand that the challenges have only just begun.


  1. Phelan D, Kim JH, Chung EC. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol 2020. [Epub ahead of print].

Clinical Topics: Sports and Exercise Cardiology

Keywords: Sports, COVID-19, Pandemics, Severe Acute Respiratory Syndrome, severe acute respiratory syndrome coronavirus 2, Sports Medicine, Athletes

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