On June 12, 2021, during a UEFA European Football Championship match between Denmark and Finland, Christian Eriksen, the 29-year-old captain of the Danish team, collapsed on the field, experiencing a sudden cardiac arrest on a live international broadcast. The widely disseminated clip is difficult to watch. Fortunately, an effective emergency action plan was in place, and Eriksen was successfully resuscitated on the field and transported to a nearby hospital. He was discharged less than a week later, after the placement of an implantable cardioverter defibrillator. Within a year, Eriksen remarkably returned to the pitch, and on March 26, 2022, he scored a goal with his first touch playing once again for the Danish national team.

While Eriksen's story is to be celebrated as a triumphant outcome of emergency action planning executed by the training and medical teams, the early public reactions should also serve as a cautionary tale for our sports cardiology community in this modern social media landscape. Almost immediately after Eriksen's collapse, false rumors that attempted to link his cardiac arrest to the COVID-19 vaccine were spread online, which were quickly discredited by team officials, who stated that he had not been vaccinated at the time of the arrest.^1,2 Nonetheless, speculative theories on social media outlets continued to spread, and prominent public figures also contributed to this dissemination of misinformation, inaccurately amplifying debunked reports of unidentified athletes dying on the field from COVID-19 vaccination.³

A comparable situation occurred earlier in the pandemic, when a University of Florida basketball player, Keyontae Johnson, collapsed during a game. Thankfully, he too was ultimately resuscitated, but initial reactions on social media included rumors that his event was related to his prior COVID-19 illness several months beforehand. There were no reputable sources to support this link, but such speculation generated unnecessary pressure on school officials to divulge medical details, clearly at the risk of violating Johnson's privacy.⁴ Months later, medical experts who reviewed Johnson's data confirmed that his collapse was not related to COVID-19.⁵

Indeed, the COVID-19 pandemic has brought public attention to the potential association of viral infections with sudden cardiac death in athletes. One of the concerns early in the pandemic was the unknown frequency with which the SARS-CoV-2 virus might cause myocarditis in athletes. There was an urgent call for data from the sports cardiology community. Subsequent registries were constructed of collegiate^6,7 and professional⁸ athletes with prior COVID-19. These data were used to inform updated return-to-play recommendations⁹ and most recently the American College of Cardiology COVID-19 Expert Consensus Decision Pathway.¹⁰ Led by this expert guidance, there have not been any known cases of COVID-19-related acute cardiac events in these registries.¹¹

Trusted medical advice has become a prized resource throughout this pandemic. We have seen more clinicians and scientists become "verified" with blue checkmarks on Twitter and other platforms. Many embraced this opportunity to provide their informed insights on the state of the pandemic, using "tweetorials" and threads to lead responsible public discourse on important matters such as COVID-19 treatments and SARS-CoV-2 variant implications. Accounts from prominent physicians and scientists shared data from around the world in real-time. Indeed, the pandemic transformed the pace and means of scientific communication.¹²

Yet, these instant and unfiltered communications also pose the significant risk of making premature statements and unintentionally propagating political narratives. In its latest guidelines for professionalism in the use of social media, the American Medical Association states: "Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students) and can undermine public trust in the medical profession."¹³ While these guidelines were written in 2010, they remain just as prescient now. As stated above, trainees particularly should heed caution, but professionals at all stages of their careers are just as vulnerable to the inadvertent consequences of an underdeveloped tweet.

Eriksen's collapse was not the first high-profile sudden cardiac arrest in professional sports, and it certainly will not be the last. Even with the implementation of the best cardiac screening strategies for athletes, on-field collapses will inevitably continue to happen. While prior cases such as the tragic deaths of Hank Gathers and Reggie Lewis have helped strengthen current efforts of pre-participation screening and emergency action planning, Eriksen's contemporary, mid-pandemic case hopefully will serve as a reminder of our duty as medical professionals to communicate accurate public health information with efforts to do so swiftly but not rashly. Sports cardiology leaders should be commended for their rapid collection of high-quality athlete data and quick incorporation into updated return-to-play recommendations. While this pandemic will almost assuredly continue to bring surprises, we need to emphasize the importance of tempering visceral reactions to these curveballs, instead using social media deliberately and intentionally. We have entered a new era in which the line between journalism and medical opinion continues to blur. While we can take advantage of this opportunity to effectively inform each other and educate the public, we should humbly respect the risks of engaging in these platforms and contribute to the signal, not the noise.

References

1. Kessler Glenn. How the falsehood of athletes dying of coronavirus vaccines spread (washingtonpost.com). 2022. Available at: https://www.washingtonpost.com/politics/2022/02/01/how-falsehood-athletes-dying-covid-vaccines-spread/. Accessed 06/01/2022.
2. Inter director says Eriksen did not have COVID and was not vaccinated (reuters.com). 2021. Available at: https://www.reuters.com/lifestyle/sports/eriksens-former-cardiologist-says-he-had-no-history-heart-concerns-2021-06-13/. Accessed 06/01/2022.
3. Schulte L. Fact-check: Are athletes dying from the COVID-19 vaccine on the playing field? (statesman.com). 2022. Available at: https://www.statesman.com/story/news/politics/politifact/2022/02/01/fact-check-athletes-dying-covid-19-vaccine-playing-field/9287487002/, Accessed 06/01/2022.
4. Forde P. Florida's Balancing Act: Protect Keyontae Johnson's Privacy While Being Transparent on Risks (si.com). 2020. Available at: https://www.si.com/college/2020/12/18/florida-balancing-act-keyontae-johnson. Accessed 06/01/2022.
5. Medcalf M. Florida forward Keyontae Johnson's collapse unrelated to COVID-19, family says (espn.com). Available at: https://www.espn.com/mens-college-basketball/story/_/id/30828219/florida-forward-keyontae-johnson-collapse-unrelated-covid-19-family-says. Accessed 06/01/2022.
6. Daniels CJ, Rajpal S, Greenshields JT, et al. Prevalence of clinical and subclinical myocarditis in competitive athletes with recent SARS-CoV-2 infection: results from the Big Ten COVID-19 Cardiac Registry. JAMA Cardiol 2021;6:1078-87.
7. Moulson N, Petek BJ, Drezner JA, et al. SARS-CoV-2 cardiac involvement in young competitive athletes. Circulation 2021;144:256-66.
8. Martinez MW, Tucker AM, Bloom OJ, et al. Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening. JAMA Cardiol 2021;6:745-52.
9. Kim JH, Levine BD, Phelan D, et al. Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play. JAMA Cardiol  2021;6:219-27.
10. Gluckman TJ, Bhave NM, Allen LA, et al. 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection and return to play. J Am Coll Cardiol 2022;79:1717–56.
11. Petek BJ, Moulson N, Drezner JA, et al. Cardiovascular outcomes in collegiate athletes after SARS-CoV-2 infection: 1-year follow-up from the outcomes registry for cardiac conditions in athletes. Circulation 2022;145:1690–92.
12. Brainard J. Riding the twitter wave. Science 2022;375:1344-47.
13. American Medical Association. Professionalism in the use of social media (ama-assn.org). 2022. Available at: https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media. Accessed 06/01/2022.

Clinical Topics: Arrhythmias and Clinical EP, COVID-19 Hub, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Sports, Sports Medicine, Social Media, COVID-19, COVID-19 Vaccines, SARS-CoV-2, Pandemics, Public Health, American Medical Association, Defibrillators, Implantable, Myocarditis, Patient Discharge, Return to Sport, Students, Medical, Vaccination, Information Dissemination, Communication, Death, Sudden, Cardiac, Heart Arrest, Registries, Hospitals, Athletes

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