New Return-to-Play Recommendations for Athletes With COVID-19

Fran Lowry

November 02, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The latest recommendations from sports cardiologists on getting athletes with COVID-19 back on the playing field safely emphasize a more judicious approach to screening for cardiac injury.

The new recommendations, made by the American College of Cardiology's Sports and Exercise Cardiology Section, are for adult athletes in competitive sports and also for two important groups: younger athletes taking part in competitive high school sports, and older athletes aged 35 and older, the Masters athletes, who continue to be active throughout their lives. The document was published online October 26 in JAMA Cardiology.

Because of the evolving nature of knowledge about COVID-19, updates on recommendations for safe return to play for athletes of all ages will continue to be made, senior author Aaron L. Baggish, MD, director of the Cardiovascular Performance Program at Massachusetts General Hospital, Boston, said.

"The recommendations we released in May were entirely based on our experience taking care of hospitalized patients with COVID-19; we had no athletes in this population. We used a lot of conservative guesswork around how this would apply to otherwise healthy athletes," Baggish told | Medscape Cardiology.

"But as sports started to open up, and we started to see large numbers of first professional and then college athletes come back into training, we realized that we needed to stop and ask whether the recommendations we put forward back in May were still appropriate," Baggish said.

"Once we started to actually get into the trenches with these athletes, literally hundreds of them, and applying the testing strategies that we had initially recommended in everybody, we realized that we probably had some room for improvement, and that’s why we reconvened, to make these revisions," he said.

Essentially, the recommendations now urge less cardiac testing. "Cardiac injury is not as common as we may have originally thought," said Baggish.

"In the early days of COVID, people who were hospitalized had evidence of heart injury, and so we wondered if that prevalence would also be applicable to otherwise young, healthy people who got COVID. If that had been the case, we would have been in big trouble with respect to getting people back into sports. So this is why we started with a conservative screening approach and a lot of testing in order to not miss a huge burden of disease," he said.

"But what we've learned over the past few months is that young people who get either asymptomatic or mild infection appear to have very, very low risk of having associated heart injury, so the need for testing in that population, when people who have infections recover fully, is almost certainly not going to be high yield," Baggish said.

First Iteration of the Recommendations

Published in May in the early weeks of the pandemic, the first recommendations for safe return to play said that all athletes should stop training for at least 2 weeks after their symptoms resolve, then undergo "careful, clinical cardiovascular evaluation in combination with cardiac biomarkers and imaging."

Additional testing with cardiac MRI, exercise testing, or ambulatory rhythm monitoring was to be done "based on the clinical course and initial testing."

But experts caution that monitoring on such a scale in everyone is unnecessary and could even be counterproductive.

"Sending young athletes for extensive testing is not warranted and could send them to unnecessary testing, cardiac imaging, and so on," Baggish said.

Only those athletes who continue to have symptoms or whose symptoms return when they get back to their athletic activities should go on for more screening.

"There, in essence, is the single main change from May, and that is a move away from screening with testing everyone, [and instead] confining that to the people who had moderate or greater severity disease," he said.

Both iterations of the recommendations end with the same message.

"We are at the beginning of our knowledge about the cardiotoxic effects of COVID-19 but we are gathering evidence every day," said Baggish. "Just as they did earlier, we acknowledge that our approaches are subject to change when we learn more about how COVID affects the heart, and specifically the hearts of athletes. This will be an ongoing process."

Something to Lean On

The recommendations are welcome, said James E. Udelson, MD, chief of the Division of Cardiology at Tufts Medical Center, Boston, Massachusetts, coauthor of an accompanying editorial.

"It was a bit of the wild west out there, because each university, each college, all with good intentions, had been all struggling to figure out what to do, and how much to do. Probably the most important message from this new paper is the fact that now there is something out there that all coaches, athletes, families, schools, trainers can get some guidance from," Udelson told | Medscape Cardiology.

Refining the cardiac screening criteria was a necessary step, Udelson said.

"How much cardiac imaging do you do? That is a matter of controversy," said Udelson, who coauthored the commentary with Tufts cardiologist Ethan Rowin, MD, and Michael A. Curtis, MEd, a certified strength and conditioning specialist at the University of Virginia. "The problem is that if you use a very sensitive imaging test on a lot of people, sometimes you find things that you really didn't need to know about. They're really not important. And now, the athlete is told he or she cannot play for 3 months because they might have myocarditis.

"Should we be too sensitive, meaning do we want to pick up anything no matter whether it's important or not?" he added. "There will be a lot of false positives, and we are going to disqualify a lot of people. Or do you tune it a different way?"

Udelson said he would like to see commercial sports donate money to support research into the potential cardiotoxicity of COVID-19.

"If the organizations that benefit from these athletes, like the National Collegiate Athletic Association and professional sports leagues, can fund some of this research, that would be a huge help," Udelson said.

"These are the top sports cardiologists in the country, and they have to start somewhere, and these are all based on what we know right now as well as their own extensive experience. We all know that we are just at the beginning of our knowledge of this. But we have to have something to guide this huge community out there that is really thirsty for help."

Baggish reports receiving research funding for the study of athletes in competitive sports from the National Heart, Lung, and Blood Institute; the National Football League Players Association; and the American Heart Association; and receiving compensation for his role as team cardiologist from the US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. Udelson has disclosed no relevant financial relationships.  

JAMA Cardiol. Published online October 26, 2020. Full text, Editorial

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