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Prevalence of Inflammatory Heart Disease Among Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play Cardiac Screening

Our take —

This large case-series found a low prevalence of myocardial injury through return to play cardiac screening after resolution of symptomatic or asymptomatic SARS-CoV-2 infection among professional league athletes in the US and Canada. Cardiac screening identified 30/789 (3.8%) athletes with abnormalities in one or more of the initial parameters. Subsequent evaluation among those with abnormalities confirmed just five athletes (0.6% of the total cohort) with evidence of myocardial (n=3) or pericardial inflammation (n=2) on cardiac MRI, all of whom had moderate symptoms while ill with COVID-19; these individuals were not cleared to return to play. There were no adverse cardiovascular outcomes in short term follow-up among those athletes who cleared cardiac screening and returned to play. The prevalence of myocardial injury after SARS-CoV-2 infection found in this population of healthy recovered young, predominantly male professional athletes, many who had asymptomatic infection, is likely to be lower than that among the general population, but highlighted the importance of disease severity/symptoms as a prognostic factor for myocardial injury. The low yield among athletes with prior asymptomatic infection supports the American College of Cardiology expert consensus panel recommendation that screening is limited to athletes who had symptomatic infection. Furthermore, the study findings substantiate the judicious use of advanced imaging such as cardiac MRI as a downstream test option rather than for broad, first line screening.

Study design

Case Series

Study population and setting

This study examined the prevalence of myocardial injury after the resolution of symptoms of laboratory-confirmed SARS-CoV-2 infection among 789 professional athletes in six major North American sports leagues (Major League Soccer, Major League Baseball, National Hockey League, the National Football League, and the men’s and women’s National Basketball Associations). Prior to resuming activity, athletes who tested positive for SARS-CoV-2, irrespective of symptoms, underwent downstream cardiac evaluation after the resolution of symptoms following the American College of Cardiology (ACC) return to play (RTP) screening algorithm. This study included data from all athletes who underwent RTP cardiac assessment between May and October 2020. Cardiac screening included cardiac enzymes (troponin), electrocardiogram (ECG) and transthoracic echocardiogram; those with abnormal results underwent further cardiac testing with cardiac magnetic resonance imaging (CMR) and/or stress echocardiography, at the discretion of the team physicians, and events were reported through December 2020. The case data were deidentified and pooled by Columbia University.

Summary of Main Findings

Of the 789 athletes with SARS-CoV-2 infection (98.5% male; mean age 25 years; 74% tested by PCR), 42% had been asymptomatic for the duration of their infection while 58% had mild to moderate or pauci-symptomatic COVID-19 illness. Only one athlete was monitored overnight in a healthcare facility with COVID-19; none were hospitalized for or had cardiopulmonary symptoms. The median time between SARS-CoV-2 test and cardiac screening was 17 days (3-156 days). There were 30/789 (3.8%) athletes with abnormalities on RTP screening tests; 6 (0.8%) had elevated troponin levels, 10 (1.3%) had ECG abnormalities concerning for myocardial injury and 20 (2.5%) had abnormalities in their echocardiograms. Those athletes underwent further downstream cardiac evaluation; 27 had CMR and 15 had stress echocardiograms (12 had both tests). There were no abnormalities in the stress echocardiograms that were performed. On CMR, three athletes met criteria for myocarditis (myocardial inflammation) and two had imaging evidence of pericarditis (pericardial inflammation) (0.6% of the total cohort). All 5 athletes with CMR abnormalities previously had mild to moderately symptomatic SARS-CoV-2 infection (loss of smell or taste, cough and/or fatigue). On the other hand, 15 athletes who had echocardiographic abnormalities and four out of six who had troponin elevation had normal CMR and returned to play. Resting ECGs had particularly low specificity as a screening test. All athletes with normal cardiac screening RTP testing and those with normal CMR returned to their normal sports activities without reporting any cardiac symptoms up to December 2020.

Study Strengths

The health care staff associated with each team followed the RTP cardiac screening algorithm recommended by an American College of Cardiology (ACC) expert consensus panel. However, they departed from the ACC guidelines by applying the same screening algorithm to all athletes who tested positive for SARS-CoV-2, including asymptomatic cases, which provides a broader and more systematic view of the prevalence of cardiovascular sequelae of SARS-CoV-2.

Limitations

Predominantly male athletes were included. The screening algorithm was performed after the resolution of symptoms and therefore represents a healthy recovered population, excluding athletes with unresolved symptoms who may have a higher likelihood of persisting myocardial abnormalities. There was no centralization of the cardiac testing protocol, which was individually directed by each team’s medical staff nor was cardiac testing interpretation centrally performed. Study athletes had wide variation in the time interval between their cardiac evaluation and diagnosis of COVID-19 infection (3-156 days). Some cardiac abnormalities due to COVID-19 may have been underestimated but missed due to delayed cardiac evaluation. There were no significant adverse outcomes observed after return to play, though follow-up duration was short.

Value added

The study adds valuable knowledge on the prevalence of myocardial injury among healthy professional athletes recovering from COVID-19 and supports the safe return to play with a judicious cardiac testing protocol.

This review was posted on: 5 April 2021