Inflammatory Heart Disease in Athletes With Prior COVID-19

Quick Takes

  • Early in the pandemic, the major North American professional sports leagues instituted conservative return-to-play cardiac testing programs based on ACC Sports and Exercise Cardiology Section expert consensus recommendations for athletes recovering from COVID-19 infection.
  • This study reports a low prevalence of clinically detected inflammatory heart disease and no adverse cardiac events in those undergoing cardiac screening and returning to play from May–October 2020.

Study Questions:

What is the prevalence of clinically detectable inflammatory heart disease in professional athletes with prior coronavirus disease 2019 (COVID-19) infection?

Methods:

The North American professional sports leagues (Major League Soccer, Major League Baseball, National Hockey League, National Football League, and the men’s and women’s National Basketball Association) established mandatory cardiac screening requirements for all players, even if asymptomatic, who had tested positive for COVID-19 prior to resumption of team-organized training. Initial testing was comprised of troponin levels, electrocardiography (ECG), and resting echocardiography (echo). Cardiac magnetic resonance imaging (CMR) and/or stress echo was ordered based on abnormalities on the initial tests. Cross-sectional data from May–October 2020 were collected.

Results:

Out of 789 professional athletes (mean age 25 years); 777 were men (98.5%), 460 (58.3%) had had moderate symptoms, 329 (41.7%) were asymptomatic or minimally symptomatic, and 586 (74.4%) had COVID-19 positivity determined via polymerase chain reaction (PCR) testing. One patient was observed overnight in the hospital, but no athletes exhibited significant cardiac or pulmonary symptoms. For those testing positive by PCR, cardiac screening was performed a mean of 19 days (range, 3-156 days) after a positive test result: the tightest window was in Major League Soccer at 13-16 days. Thirty athletes (3.8%) had abnormal findings (six or 0.8% troponin; 10 or 1.3% ECG; 20 or 2.5% echo). Out of this 30, five (0.6%) had CMR findings suggestive of inflammatory heart disease (three myocarditis, two pericarditis) that resulted in restriction from sport. No adverse cardiac events occurred in those who returned to play.

Conclusions:

Cardiac screening consisting of troponin level, ECG, echo, and CMR and/or stress echo only as needed in professional athletes with prior COVID-19 infection found few cases of inflammatory heart disease and facilitated safe return to professional sports.

Perspective:

This study is the largest to date evaluating the presence of inflammatory heart disease (myocarditis, pericarditis) in athletes returning to play after COVID-19 infection. It represents an impressive collaborative effort between professional sports organizations. The findings support the use of expert consensus recommendations on return-to-play screening from the American College of Cardiology (ACC) Sports and Exercise Cardiology Section first published in May 2020 and updated in October 2020.

Between troponin level, ECG, and echo, echo was most helpful in detecting inflammatory disease but also led to additional testing in about 2% that did not detect any pathology. Also of note, there were no reported incidental findings on CMR, such as late gadolinium enhancement at the right ventricular insertion point. As the authors acknowledge, CMR was not ordered routinely and thus signs of subclinical inflammatory disease may have been missed. Whether those potential findings would be of clinical significance is not yet known but will be the subject of forthcoming studies. More CMR reference/control data are also needed in athletes based on age and training and in those, whether athletes or not, with non–COVID-19 infections such as influenza.

This study reflects the accomplishment of a ‘real-world’ approach to return-to-play screening, but the authors recognize other limitations: noncentralized referral, performance, and interpretation of testing; variability in timing of testing; lack of long-term follow-up (but ongoing); and predominantly male cohort.

Disclosures: Dr. Chung is Chair of the ACC Sports and Exercise Cardiology Leadership Council and a Steering Committee member of the Big Ten Cardiac Registry.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and Imaging

Keywords: Athletes, Coronavirus, COVID-19, Diagnostic Imaging, Echocardiography, Electrocardiography, Exercise, Magnetic Resonance Imaging, Myocarditis, Pericarditis, Polymerase Chain Reaction, Primary Prevention, Troponin


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