Screening for Cardiac Involvement in Athletes Recovering From COVID-19

Phelan D, Kim JH, Elliott MD, et al.
Screening of Potential Cardiac Involvement in Competitive Athletes Recovering From COVID-19: An Expert Consensus Statement. JACC Cardiovasc Imaging 2020;13:2635-2652.

The following are key points to remember from this expert consensus statement on screening of potential cardiac involvement in competitive athletes recovering from coronavirus disease (COVID-19).

Quick Takes

  1. COVID-19 can cause short- and long-term cardiovascular complications that will impact return to play (RTP) decisions: of particular concern is the potential for exercise in the context of ongoing viral myocarditis to exacerbate illness and/or trigger serious arrhythmias, increasing the risk of sudden death.
  2. Because we are still learning about the impact of COVID-19 in athletes, how to thoughtfully perform preparticipation screening has been the subject of much discussion.
  3. This paper comprehensively reviews the strengths and limitations of different imaging modalities and provides context for their implementation in RTP decision making.


  1. This is a consensus statement by an international panel of experts. Four aims of the paper are to: a) define the cardiac complications of COVID-19 infection in athletes, b) provide guidance on differentiating athletic heart adaptations from potential COVID-19–related pathologic complications, c) review indications for additional downstream imaging, and d) define the strengths and limitations of various imaging modalities in assessing for COVID-19–related cardiac complications.

Current Screening Strategies in Athletes After COVID-19

  1. A thorough preparticipation history and physical remains central to any evaluation of the athlete; symptoms should guide appropriate workup.
  2. Consensus recommendations, including those from the ACC Sports and Exercise Cardiology Leadership Council, have evolved over the last 6 months; asymptomatic and mildly symptomatic athletes probably do not need as much testing as first thought; longitudinal data will guide further recommendations.
  3. For those with moderate or worse symptomatology, cardiac testing (electrocardiogram [ECG], high-sensitivity troponin, echocardiogram) is still recommended at this time prior to RTP.

Practical Issues for the Screening of Athletes After Recovery From COVID-19

  1. Even before COVID-19, preparticipation evaluations did not fit a “one size fits all” approach; protocols need to account for local resources and expertise and the population being screened. Familiarity with findings consistent with exercise-induced cardiac remodeling is essential.
  2. ECG, high-sensitivity troponin, and echocardiogram together will enhance any evaluation but separately have some limitations: the ECG lacks sensitivity for myocarditis, troponin assays lack standardization in athletes and can be elevated after exercise, and echocardiograms require added cost, access, and expertise.

Imaging Athletes’ Hearts and COVID-19 Considerations

  1. Echocardiographic findings consistent with myocarditis include regional wall motion abnormalities, global left ventricular (LV) systolic dysfunction, diastolic dysfunction, and increased wall thickness due to edema.
  2. Athletic remodeling tends to be symmetric and affect all four chambers; LV ejection fraction should be normal to low-normal and diastolic function should be preserved; left atrial reservoir function should also be normal.
  3. In athletes, right ventricular (RV) dilation is usually no more than moderate, and when present, is matched similarly in the LV; RV dilation and mildly abnormal systolic function are common in endurance athletes.
  4. Because RV pathology is frequently seen after severe COVID-19 infection, careful qualitative and quantitative assessment is needed; additional cardiac sequelae include pericarditis with or without pericardial effusion.
  5. Echocardiography is the first-line imaging modality in most cases; cardiac magnetic resonance imaging (CMR) can further characterize the RV, delineate pericardial enhancement, and identify coexisting myocarditis.

CMR Imaging

  1. CMR is considered the gold standard modality for assessing ventricular function; its utility in evaluating ventricular inflammation, edema, and scar renders it an important diagnostic tool in those with a moderate to high pretest probability of myocarditis.
  2. Indications for adjunctive CMR in the evaluation of an athlete include persistent symptoms, sustained troponin elevation, ECG with abnormal repolarization changes, ventricular arrhythmias, regional wall motion abnormalities, and pericardial effusion.
  3. Recent studies have reported a high prevalence of cardiac abnormalities on CMR in patients recovering from COVID-19. The clinical significance of these abnormalities is still unclear but will hopefully be elucidated with emerging registry data that include appropriate control groups.
  4. CMR should be performed at experienced centers with proficiency in T1 and T2 mapping pulse sequences and parameters, data analysis, and reporting; a CMR abnormality of native T1 or T2 (>2 standard deviations above local normal reference mean), extracellular volume (>30%), or any late gadolinium enhancement (LGE) can support a clinical diagnosis of myocarditis.

Other Imaging Modalities

  1. Coronary computed tomography angiography (CTA) may be helpful for individualized secondary risk stratification in those with ongoing chest symptoms, but it should not be ordered as part of a “one-stop shop” study.
  2. Positron emission tomography (PET) could be considered if echocardiography and CMR are suboptimal or contraindicated.
  3. In cases of myocarditis, exercise testing after the convalescence period is helpful in assessing for exercise-induced ventricular arrhythmias.

RTP Considerations for Athletes With Abnormal Findings on Imaging and Recommendations for Follow-Up Testing

  1. Current recommendations call for limiting strenuous exercise in athletes with myocarditis for 3-6 months to allow a reasonable amount of time for active inflammation to resolve; RTP would then depend on normalization of abnormal findings at the time of diagnosis such as LV systolic function, troponin level and inflammatory markers, and clinically relevant arrhythmias and/or ECG changes.
  2. The timing and role of serial CMR has not been established, but persistent LGE may be associated with worse prognosis.
  3. Shared decision making continues to be an essential component of RTP discussions.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Exercise, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Arrhythmias, Cardiac, Athletes, Coronary Angiography, COVID-19, Death, Sudden, Diagnostic Imaging, Echocardiography, Electrocardiography, Exercise, Exercise Test, Magnetic Resonance Imaging, Myocarditis, Pericardial Effusion, Pericarditis, Physical Examination, Secondary Prevention, Troponin, Ventricular Dysfunction, Left

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