The following are key points to remember from the 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults including myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play:

Myocarditis and Other Myocardial Involvement

1. Myocarditis is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Myocarditis is defined by: a) cardiac symptoms (e.g., chest pain, dyspnea, palpitations, syncope); b) elevated cardiac troponin (cTn); and c) abnormal electrocardiographic, echocardiographic, cardiac magnetic resonance imaging (CMR), and/or histopathologic findings on biopsy or postmortem evaluation in the absence of flow-limiting coronary artery disease.
2. Hospitalization is recommended for patients with definite myocarditis, ideally at an advanced heart failure center. Patients with fulminant myocarditis should be managed at centers with expertise in advanced heart failure, mechanical circulatory support, and other advanced therapies.
3. Patients with myocarditis and coronavirus disease 2019 (COVID-19) pneumonia (with an ongoing need for supplemental oxygen) should be treated with corticosteroids.
4. For patients with suspected pericardial involvement, treatment with nonsteroidal anti-inflammatory drugs, colchicine, and/or prednisone is reasonable.
5. Intravenous corticosteroids may be considered in those with suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or multisystem inflammatory syndrome in adults (MIS-A). Empiric use of corticosteroids may also be considered in those with biopsy evidence of severe myocardial infiltrates or fulminant myocarditis, balanced against infection risk.
6. As appropriate, guideline-directed medical therapy for heart failure should be initiated and continued after hospital discharge.
7. Myocarditis following COVID-19 mRNA vaccination is rare. The highest observed rates have been in young male individuals (aged 12-17 years) after the second vaccine dose. COVID-19 vaccination is associated with a very favorable benefit-to-risk ratio for all age and sex groups evaluated thus far.
8. In general, vaccine-associated myocarditis should be diagnosed, categorized, and treated in a manner analogous to myocarditis following SARS-CoV-2 infection.

Post-Acute Sequelae of SARS-CoV-2 Infection (PASC)

1. PASC is defined as a constellation of new, returning, or persistent health problems experienced by individuals 4 or more weeks after SARS-CoV-2 infection.
2. PASC cardiovascular disease (PASC-CVD) refers to a broad group of cardiovascular conditions that include, but are not limited to, myocarditis and other forms of myocardial involvement, pericarditis, new or worsening myocardial ischemia, microvascular dysfunction, nonischemic cardiomyopathy, thromboembolism, cardiovascular sequelae of pulmonary disease, and arrhythmia.
3. PASC cardiovascular syndrome (PASC-CVS) is a heterogeneous disorder that includes widely ranging cardiovascular symptoms, without objective evidence of cardiovascular disease using standard diagnostic testing. Common symptoms include orthostatic intolerance, exercise intolerance, post-exertional malaise, palpitations, chest pain, and dyspnea.
4. For patients with suspected PASC, a reasonable initial testing approach includes: a) basic laboratory testing (including cTn); b) an electrocardiogram (ECG); c) a transthoracic echocardiogram; d) an ambulatory rhythm monitor; e) chest imaging (radiograph and/or computed tomography); and/or f) pulmonary function tests.
5. Cardiology consultation is recommended for patients with PASC who have: a) abnormal cardiac test results; b) known cardiovascular disease with new or worsening symptoms or signs; c) documented cardiac complications during SARS-CoV-2 infection; and/or d) persistent cardiopulmonary symptoms that are not otherwise explained.
6. Recumbent or semi-recumbent exercise (e.g., rowing, swimming, or cycling) is recommended for PASC-CVS patients with tachycardia, exercise/orthostatic intolerance, and/or deconditioning, with transition to upright exercise as orthostatic intolerance improves. Exercise duration should also be short (5-10 minutes/day) initially, with gradual increases as functional capacity improves.
7. Salt and fluid loading represent nonpharmacological interventions that may provide symptomatic relief for patients with tachycardia, palpitations, and/or orthostatic hypotension. Beta-blockers, nondihydropyridine calcium channel blockers, ivabradine, fludrocortisone, and midodrine may be used empirically as well.

Return to Play

1. For both competitive and recreational athletes, the recommended duration of abstinence from exercise following SARS-CoV-2 infection depends on the severity of illness. Those who are asymptomatic may resume exercise after 3 days of abstinence during self-isolation. Athletes with mild or moderate noncardiopulmonary symptoms may resume exercise after their symptoms have resolved. Individuals with remote infection (≥3 months) without ongoing cardiopulmonary symptoms may resume exercise without the need for additional testing. Athletes with myocarditis should abstain from exercise for 3-6 months.
2. Athletes recovering from SARS-CoV-2 infection with ongoing cardiopulmonary symptoms and/or those requiring hospitalization with increased suspicion for cardiac involvement should undergo triad testing (ECG, cTn, and echocardiogram). Triad testing should also be performed in those developing new cardiopulmonary symptoms after resumption of exercise training.
3. CMR is recommended if triad testing is abnormal or cardiopulmonary symptoms persist.
4. Maximal-effort exercise testing and/or ambulatory rhythm monitoring may be helpful in the evaluation of athletes with persistent cardiopulmonary symptoms or CMR findings suggestive of myocardial (or pericardial) involvement. Maximal-effort exercise testing should only be performed, however, after myocarditis has been excluded with CMR.
5. CMR to screen athletes who are asymptomatic or with noncardiopulmonary symptoms is likely to be low yield.
6. Repeat cardiac testing is not warranted in athletes with recurrent SARS-CoV-2 infection in the absence of cardiopulmonary symptoms.

Clinical Topics: Arrhythmias and Clinical EP, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and Imaging

Keywords: Arrhythmias, Cardiac, Athletes, Biopsy, Cardiac Imaging Techniques, Chest Pain, COVID-19, Diagnostic Techniques, Cardiovascular, Drug Therapy, Dyspnea, Echocardiography, Electrocardiography, Exercise, Heart Failure, Hemodynamics, Immunosuppression, Inflammation, Magnetic Resonance Imaging, Mass Screening, Motor Activity, Myocarditis, Myocardium, Pericardial Effusion, Pericarditis, Pneumonia, Postural Orthostatic Tachycardia Syndrome, Registries, Safety, Secondary Prevention, Shock, Troponin, Vaccination, Vaccines

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