SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes

Quick Takes

  • The prevalence of cardiac involvement by SARS-CoV-2 infection and subsequent clinical implications in the student athlete population remain the subject of much investigation.
  • Further understanding the impact of SARS-CoV-2/COVID-19 infection on the heart of the athlete is essential, as cardiac involvement could portend increased risk for short- and long-term adverse cardiovascular events.
  • This study, the largest to date, reports on a national cohort of collegiate athletes recovered from SARS-CoV-2 infection.

Study Questions:

What are the prevalence and clinical implications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cardiac involvement in young competitive athletes?

Methods:

Between September 1, 2020 and December 31, 2020, survey data were collected from 42 colleges/universities. The primary outcome was the prevalence of definite, probable, or possible SARS-CoV-2 cardiac involvement based on adapted definitions from the 2018 Updated Lake Louise Criteria for cardiovascular magnetic resonance imaging (CMR). Secondary outcomes included results from the cardiac testing “triad” (troponin, electrocardiogram [ECG], echocardiogram), potential clinical or demographic predictors for cardiac involvement, and adverse cardiovascular events.

Results:

The study cohort was comprised of 19,378 athletes (32% female) tested across the 42 participating sites: 3,018 tested positive for SARS-CoV-2 infection and formed the study group, and 2,820 athletes underwent at least one element of cardiac “triad” testing as well as CMR if deemed clinically indicated. Most athletes either had mild or no symptoms (62%), and the three most common symptoms were loss of taste or smell, headache, and sore throat. Cardiopulmonary symptoms were present in 13%. The rate of incidental non–coronavirus disease 2019 (non–COVID-19) diagnoses, such as atrial septal abnormality, bicuspid aortic valve, and Wolff-Parkinson-White ECG pattern, was 1.9%.

CMR as a primary screening modality was performed in 198 athletes. Abnormal findings were detected at the following rates: ECG (21/2,999; 0.7%), cardiac troponin (24/2,719; 0.9%), and echo (24/2,556; 0.9%). Definite, probable, or possible SARS-CoV-2 cardiac involvement was identified in 21/3,018 (0.7%) athletes. The 21 included 15/2,820 (0.5%) who underwent cardiac “triad” testing and/or had moderate or worse symptoms, and 6/198 (3.0%) who had primary screening CMR. The aforementioned 15 were also among 119 that underwent clinically indicated CMR. Hence, the diagnostic yield of CMR for SARS-COV-2 cardiac involvement was 4.2 times higher for a clinically indicated CMR (15/119; 12.6%) compared to a primary screening CMR (6/198; 3.0%). Adjusted predictors of SARS-CoV-2 cardiac involvement included cardiopulmonary symptoms or at least one abnormal triad test. In longitudinal follow-up (median follow-up 113 days), there was one (0.03%) adverse cardiac event deemed unrelated to SARS-CoV-2 infection.

Conclusions:

SARS-CoV-2 cardiac involvement among young competitive athletes has a low prevalence of cardiac involvement and a low short-term risk of clinical events.

Perspective:

This is an impressively large and detailed multicenter observational cohort of collegiate athletes. The prevalence of clinically identified cardiac involvement is similar to a recent study from multiple professional sports leagues.

The findings support recommendations outlined by experts from the ACC Sports and Exercise Cardiology section in October 2020: that is, asymptomatic or mildly symptomatic athletes fully recovered from COVID-19 infection do not require cardiac testing prior to returning to sport. For athletes with moderate or worse symptoms, and/or cardiopulmonary symptoms, cardiac evaluation inclusive of 12-lead ECG, troponin, and echo should be considered prior to return to play. CMR should also be considered based on clinical concern and testing results.

That said, the role of CMR remains unsettled. The authors chose to use “cardiac involvement” rather than “myocarditis” or “inflammation” or “injury.” This seems very reasonable, for while the CMR has emerged as the modality of choice for noninvasive assessment of myocarditis, its utilization remains nuanced. Access to CMR, acquisition and interpretation of images, and limited availability of normative data in athletes remain factors that must be taken into account. Of note, only about 11% of the study group underwent CMR, so the 3.0% “upper estimate” prevalence could be an underestimate. Additionally, this study does not address the impact of CMR abnormalities in asymptomatic subjects or the appropriate timing for follow-up CMR studies.

Limitations, as acknowledged by the authors, include heterogeneity of clinical assessments across the participating sites, reliance on testing result reports without core lab-type adjudication, and limited time of follow-up.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and Imaging

Keywords: Arrhythmias, Cardiac, Athletes, Bicuspid, COVID-19, Coronavirus, Diagnostic Imaging, Diagnostic Tests, Routine, Echocardiography, Electrocardiography, Exercise, Heart Septal Defects, Atrial, Inflammation, Magnetic Resonance Imaging, Myocarditis, Pharyngitis, Primary Prevention, SARS-CoV-2, Troponin, Wolff-Parkinson-White Syndrome


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