Athletes With COVID-19 Need Several Weeks' Rest Before Returning to Sport

By Will Boggs MD

June 02, 2020

NEW YORK (Reuters Health) - Athletes who test positive for SARS-CoV-2, the virus that causes COVID-19, should take at least two weeks off from intense or competitive exercise and even more if they show signs of myocarditis, according to two new reports.

"Unfortunately, the knowledge about medium- and long-term consequences of an infection with SARS-CoV-2 is still limited," said Dr. Christof Burgstahler of University Hospital Tuebingen and Eberhard Karls University of Tuebingen, in Germany.

"Involvement of the heart in an asymptomatic or oligosymptomatic infection cannot always be excluded with certainty. It should, therefore, be kept in mind that cardiac complications such as myocarditis may also occur," he told Reuters Health by email.

Dr. Burgstahler and colleagues address concerns about COVID-19-associated myocarditis in an article in European Heart Journal.

While being an athlete is not associated with an increased risk for developing severe COVID-19, numerous athletes and occasionally entire sports teams have been affected by COVID-19 infections, they note.

Even apart from COVID-19, myocarditis is one of the leading causes of sport-associated sudden cardiac death among athletes under age 35 years. Athletes frequently present with nonspecific symptoms and are not likely to be tested for SARS-CoV-2, further complicating a potential COVID-19-associated myocardial involvement or myocarditis.

The authors suggest an algorithm for return to sport for athletes with a positive SARS-CoV-2 result or with typical COVID-19 symptoms.

Because viral replication can be enhanced during vigorous activity, thereby resulting in greater damage to the heart, they recommend refraining from intensive or competitive exercise for at least two weeks in athletes diagnosed with COVID-19 but otherwise asymptomatic.

If athletes remain symptom-free and show no abnormalities in the resting ECG at the end of two weeks, they can return to participation without restriction, the authors say.

Symptomatic athletes with COVID-19 with no diagnostic evidence of myocarditis should be restricted from sports for at least two to four weeks, after which normal results of a thorough medical examination (including physical examination, resting and exercise ECG, and echocardiography) should precede their resumption of sporting activities.

Athletes found to have myocarditis should have a strict ban on sports for at least three to six months. Thereafter, they can reasonably return to training and competition if left ventricular function and cardiac dimensions have returned to normal, if clinically relevant arrhythmias are absent in Holter ECG monitoring and exercise testing, and if serum markers of inflammation and heart failure have returned to normal.

Based on previous studies and registries of acute myocarditis, athletes with a complete recovery have a very good prognosis.

"The approach does not essentially differ between competitive and recreational athletes," Dr. Burgstahler said. "However, a longer sports interruption is of course more relevant for a competitive athlete than for a recreational athlete. On the other hand, even in ambitious leisure sports, comparable volumes and intensities are completed as in competitive sports."

"Be careful!" he concluded. "COVID-19 still has many facets that we do not know exactly. Therefore, prospective registries are important to generate as much knowledge as possible."

In an editorial in the British Journal of Sports Medicine, Dr. Helder Dores and Dr. Nuno Cardim of Luz Hospital Lisbon and NOVA Medical School, also in Lisbon, present their views as sports cardiologists on the return to play after COVID-19.

Because athletes clinically recovered from a proved infection might have a subclinical myocardial injury, they recommend a complete medical evaluation before the athlete resumes training.

In the context of the COVID-19 pandemic, these exams should be performed with caution and following all recommendations regarding protective measures.

Management of athletes with abnormal findings should be similar to other cases of myocarditis, and athletes diagnosed with myocarditis or myopericarditis should be disqualified from sports participation for three to six months. Return to training and competition should be contingent on the resolution of all symptoms and abnormal findings, including significant arrhythmias, the authors say.

It is also important to keep in mind that a single athlete can be a vector of transmission. Physicians should be involved in the return-to-play decision and contribute to establish specific protocols to evaluate athletes affected by COVID-19.

Dr. Eduardo Marban of Cedars-Sinai Medical Center, in Los Angeles, who recently reviewed what is known about COVID-19 and its effect on the heart, told Reuters Health by email, "Concerns over COVID-19 myocarditis in athletes are entirely conjectural. Although elevations of cardiac biomarkers such as troponin are common in COVID-19, true myocarditis appears to be quite rare."

"The recommendations articulated here are, however, not unreasonable," said Dr. Marban, who was not involved in the two reports. "No one with diagnosed or likely myocarditis, whatever the cause, should be exercising vigorously. Even in those with mild symptoms and confirmed SARS-CoV-2 infection, it is theoretically possible that vigorous exercise could stress the heart, converting otherwise innocuous cardiac involvement into a catastrophic problem."

"But such reasoning is based on piecing together fragmentary evidence from animal studies and from previous viral epidemics," he said. "More knowledge is required before we can knowledgeably counsel athletes with COVID."

Dr. Brett Toresdahl of the Hospital for Special Surgery's Department of Primary Care Sports Medicine, in New York City, who recently addressed COVID-19 considerations for the competitive athlete, said, "The challenge right now is that the prevalence of cardiac involvement is unknown in mild cases of COVID-19, which comprise the majority of cases. Although the myocardial injury from COVID-19 is thought to be temporary, the period of time that an athlete is at increased risk of a cardiac event following COVID-19 infection is unknown."

"If research could show that all but the most severe cases of cardiac injury due to COVID-19 resolve within a month, then the vast majority of athletes wouldn't require advanced cardiovascular testing," Dr. Toresdahl, who also was not involved in the reports, told Reuters Health by email. "Since there remain so many unknowns, erring on the side of over-testing during a time like this is reasonable when resources allow for it."

Dr. Dores did not respond to a request for comments.

SOURCE: European Heart Journal, online May 20, 2020; British Journal of Sports Medicine, online May 7, 2020.