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Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play

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Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play Clinical Review & Education JAMA Cardiology | Special Communication Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play Jonathan H. Kim, MD, MSc; Benjamin D. Levine, MD; Dermot Phelan, MD, PhD; Michael S. Emery, MD, MS; Mathew W. Martinez, MD; Eugene H. Chung, MD, MSc; Paul D. Thompson, MD; Aaron L. Baggish, MD Editorial IMPORTANCE Cardiac injury with attendant negative prognostic implications is common Author Audio Interview among patients hospitalized with coronavirus disease 2019 (COVID-19) infection. Whether cardiac injury, including myocarditis, also occurs with asymptomatic or mild-severity COVID-19 infection is uncertain. There is an ongoing concern about COVID-19–associated cardiac pathology among athletes because myocarditis is an important cause of sudden cardiac death during exercise. Author Affiliations: Emory University School of Medicine, Emory OBSERVATIONS Prior to relaxation of stay-at-home orders in the US, the American College of Clinical Cardiovascular Research Cardiology’s Sports and Exercise Cardiology Section endorsed empirical consensus Institute, Atlanta, Georgia (Kim); recommendations advising a conservative return-to-play approach, including cardiac risk Institute for Exercise and stratification, for athletes in competitive sports who have recovered from COVID-19. Environmental Medicine, Texas Health Presbyterian Dallas, Dallas Emerging observational data coupled with widely publicized reports of athletes in (Levine); The University of Texas competitive sports with reported COVID-19–associated cardiac pathology suggest that Southwestern Medical Center, Dallas myocardial injury may occur in cases of COVID-19 that are asymptomatic and of mild severity. (Levine); Sanger Heart and Vascular Institute, Atrium Health, Charlotte, In the absence of definitive data, there is ongoing uncertainty about the optimal approach to North Carolina (Phelan); Sports cardiovascular risk stratification of athletes in competitive sports following COVID-19 Cardiology Center, Department of infection. Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio (Emery); CONCLUSIONS AND RELEVANCE This report was designed to address the most common Morristown Medical Center, Atlantic questions regarding COVID-19 and cardiac pathology in athletes in competitive sports, Health System, Morristown, New Jersey (Martinez); Michigan including the extension of return-to-play considerations to discrete populations of athletes Medicine, University of Michigan, not addressed in prior recommendations. Multicenter registry data documenting Ann Arbor (Chung); Hartford cardiovascular outcomes among athletes in competitive sports who have recovered from Hospital, Hartford, Connecticut COVID-19 are currently being collected to determine the prevalence, severity, and clinical (Thompson); Cardiovascular Performance Program, relevance of COVID-19–associated cardiac pathology and efficacy of targeted cardiovascular Massachusetts General Hospital, risk stratification. While we await these critical data, early experiences in the clinical Boston (Baggish). oversight of athletes following COVID-19 infection provide an opportunity to address key Corresponding Author: Aaron L. areas of uncertainty relevant to cardiology and sports medicine practitioners. Baggish, MD, Cardiovascular Performance Program, Massachusetts General Hospital, JAMA Cardiol. doi:10.1001/jamacardio.2020.5890 55 Fruit St, Yawkey Ste 5B, Published online October 26, 2020. Boston, MA 02114 ([email protected]). n May 2020, the American College of Cardiology’s Sports generally considered individuals who place a high premium and Exercise Cardiology Section generated recommenda- on training, competition, and sports achievement.10 As such, tar- I tions to promote safe return to play (RTP) for athletes geted RTP risk stratification for all athletes deserves careful involved with competitive sports after severe acute respiratory consideration. syndrome coronavirus 2 infection.1 Motivated by observations of Relaxation of stay-at-home orders across the US enabled cardiac injury in patients hospitalized with coronavirus disease many athletes to return to training and competition. In collabora- 2019 (COVID-19),2 that document1 and others3-5 proposed algo- tion with the sports medicine community and despite the current rithms for preparticipation screening, geared toward the detec- lack of supportive data, we have since accrued considerable expe- tion of COVID-19–associated cardiac complications. At present, rience overseeing RTP testing among athletes with prior the prevalence and clinical implications of COVID-19 cardiac COVID-19 infection at all levels of sport. This document was writ- pathology in athletes are unknown. However, publicized ten to address the most common questions posed by the media media reports of athletes with suspected COVID-19–induced and in clinics, athletic training rooms, and ongoing discussions myocarditis,6,7 coupled with emerging data documenting cardiac among cardiologists who participate in the care of athletes. The injury among community-based cohorts,8,9 have fueled concerns authors were selected by the Leadership Council of the Sports about the safety of athletics. The definition of an athlete and Exercise Cardiology Section of the American College of Cardi- can also be arbitrary. From enthusiasts of youth sports to ology to provide this narrative reassessment of the previous masters-level exercise (in those aged >35 years), athletes are consensus statement. jamacardiology.com (Reprinted) JAMA Cardiology Published online October 26, 2020 E1 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Université de Lausanne User on 11/06/2020 Clinical Review & Education Special Communication Coronavirus Disease 2019 and the Athletic Heart troponin (hs-cTn) levels allow detection of myocardial injury and are Part 1. COVID-19 Pathology and the Athletic Heart associated with outcomes in patients hospitalized with COVID-19,24 implications among healthy athletes with asymptomatic or mild dis- What Is Known About the Effects of COVID-19 Infection ease have yet to be established. Second, 99th-percentile assay val- on the Heart For Individuals With Mild or No Symptoms ues were not derived from athletes and should be used as a rule-in Symptoms defining mild COVID-19 include nonspecific and self- or rule-out criterion with caution.25 Third, normal hs-cTn reference limited fatigue; anosmia or ageusia; nausea, vomiting, and/or diar- ranges for athletes, stratified by age and sex, do not exist, which can rhea;headache;cough;sorethroat;andnasopharyngealcongestion.11 lead to clinical dilemmas in interpreting borderline or mildly el- Progression to moderate or severe disease and the potential need for evated values. Finally,most medical centers in the US still rely on the hospitalization are characterized by the onset of systemic symptoms less sensitive cardiac troponin assays, thus limiting standardization (persistent fever [temperature Ն100.4 °F] or chills, myalgias, severe for hs-cTn test results.26 lethargy,andhypoxiaorpneumonia)and/orcardiovascular(CV)symp- Troponin testing to screen for COVID-19 cardiac injury must be toms (dyspnea and chest pain, tightness, or pressure at rest or during performed at least 24 to 48 hours after exercise and should be re- exertion).11 In patients hospitalized with moderate or severe COVID- peated after a similar period of rest following an isolated abnormal- 19,particularlyamongthosewithunderlyingCVconditions,cardiacin- ity.Persistentlyelevatedtroponinlevelsshouldpromptdetailedchar- jury is common (>20% of cases).2,12,13 However, the pathogenesis of acterization of the myocardium with cardiac magnetic resonance COVID-19 cardiac injury is variable, with inconsistent evidence of di- imaging (CMR). In the absence of imaging findings consistent with rect myocyte viral invasion.14-16 In cases of mild or asymptomatic active myocardial inflammation,27 other systemic causes of el- COVID-19,theprevalenceandclinicalimplicationsofpathologicCVse- evated troponin must also be considered. Among athletes with per- quelae remain unknown. sistently elevated troponin levels but normal CMR, there are sev- Reportsofpresumptivemyocarditisamongseveralathleteswith eral considerations that should dictate clinical decision-making. high profiles have magnified concerns about COVID-19 CV se- Clinical presentations characterized by systemic and/or CV symp- quelae in athletes.6,7 Our combined experience suggests that most toms indicate a higher pretest probability of clinically relevant myo- athletes with COVID-19 are asymptomatic to mildly ill, and to date, carditis, thus favoring exercise restrictions for at least 3 months.28 RTP risk stratification has yielded few cases of relevant cardiac pa- In contrast, athletes with isolated hs-cTn level elevation but lower thology. However, we underscore that these observations may not pretest cardiac injury probability (because of asymptomatic or mild reflect the true prevalence and attendant prognosis of COVID-19 CV COVID-19 symptoms) may be considered for more rapid RTP, with involvement in athletes. close monitoring and gradual escalation of training intensification. The increased sensitivity of hs-cTn testing comes at the cost of re- Challenges in Determining If COVID-19 Myocardial Injury duced specificity for clinically relevant myocardial injury,which may Is Present in Athletes lead to unnecessarily prolonged exercise
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