Incidence of Cardiac Pathology Post-COVID in Pro Athletes < 1%

Debra L. Beck

March 04, 2021

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

Routine return-to-play (RTP) cardiac screening of professional athletes with previous COVID-19 infection shows less than 1% ultimately had signs of cardiac inflammation, a new study reports.

In this cohort of 789 professional athletes post-COVID infection, abnormal cardiac screening results were seen in 30 (3.8%), necessitating further testing that showed signs of cardiac inflammation in only five athletes, or 0.6% of the total cohort.

"What we really see from this large study — I think it may be larger than all the other published studies on athletes and COVID-19 heart effects — is that, first of all, our protocol has good clinical effectiveness for identifying those who may be at risk from resuming professional play, but also that in those with COVID-19 illness, the risk is really very low," said Matthew W. Martinez, MD, Morristown Medical Center, Morristown, New Jersey.

None of the athletes screened were clinically assessed as having severe COVID-19 viral illness. All five identified as having inflammatory heart disease, however, had preceding symptoms that exceeded empirical definitions of mild COVID-19.

"We defined mild basically as having symptoms from the neck up — so headache, upper respiratory infection, lack of taste or smell — those were mild symptoms. If they had fever, chills, myalgias, breathlessness, chest pain, elevated heart rate, those were moderate symptoms," said Martinez in an interview with theheart.org | Medscape Cardiology.

"It's in these who had more, let's say, high-moderate symptoms that we need to think about complications, but even there, the risk was quite low," he added.

North American professional sports leagues, including Major League Baseball, Major League Soccer, National Hockey League, National Football League, and the men's and women's National Basketball Association, implemented in early 2020 mandatory cardiac screening requirements for all players who had tested positive for COVID-19.

The RTP screening recommendations, which include troponin testing, 12-lead electrocardiography (ECG), and resting transthoracic echocardiography, were developed by the sports leagues and aligned with American College of Cardiology (ACC) recommendations for athletes testing positive for COVID-19.

The study, which was published online March 4 in JAMA Cardiology, is the first of its kind to assess the expert consensus-driven post-COVID RTP screening protocols put into place by the major North American sports leagues, as aligned with the ACC.

This study, conducted by a team led by Martinez and David J. Engel, MD, Columbia University Irving Medical Center, New York City, described the findings from athletes tested between May and October 2020.

A total of 789 professional athletes were included, of whom 460 (58.3%) had prior symptomatic COVID-19 illness and 329 (41.7%) were asymptomatic or paucisymptomatic (minimally symptomatic). All had a positive PCR test and cardiac screening was performed a mean of 19 days after that positive test result.

Abnormal screening results were seen in 30 patients, including positive troponin in six athletes (0.8%), ECG findings in 10 (1.3%), and echocardiography findings in 20 (2.5%).

Subsequent cardiac magnetic resonance imaging showed signs of myocarditis in three athletes and pericarditis in two. All were restricted from play in accordance with expert task force guidelines.

The remaining 25 athletes (83.3% of those with abnormal screening results) who underwent additional testing had no findings suggestive of acute cardiac injury and returned to play.

"What we're seeing here is the overlap between physiologic changes in the athlete's heart that may mimic pathology and actual pathology. This is where the rubber meets the road for sports cardiologists — determining if the supposed abnormality is actually normal or abnormal," said Martinez.

As of late December 2020, no clinical cardiac events have occurred in any of the athletes who have undergone cardiac screening and resumed full professional sporting activity.

The study "support[s] updated expert consensus ACC recommendations, which do not advocate for cardiovascular risk stratification in athletes who were asymptomatic or athletes with mild COVID-19 viral illness," write Martinez et al.

"For this group, we're suggesting that once your isolation period is over, assuming you have no symptoms and feel well, you can slowly return to exercising. Nothing more needs to be done," said Martinez.

Martinez disclosed personal fees from Major League Soccer as a consultant during the conduct of the study. Several of the other authors are either employed by professional sports leagues or receive personal fees from sports leagues.

JAMA Cardiology. Published online March 4, 2021. Full text

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