The COVID-19 pandemic has highlighted the intersection between sports, medicine, and society, as the safety of athletic competition in the current climate has received a great deal of attention. In May 2020, the American College of Cardiology's (ACC) Sports and Exercise Cardiology Section endorsed expert consensus recommendations for return to play (RTP) for competitive athletes who were previously infected with COVID-19.¹ In a follow-up ACC.org online poll,² 77% of medical respondents found the cardiac testing algorithm useful in clinical practice. However, while the majority felt reassured in guiding athletes using these conservative recommendations, respondents also reported absence of detected cardiac pathology in athletes screened.

Since this initial publication,¹ in combination with relaxation of national lockdown measures, small community-based observational studies have also reported evidence of potential cardiac injury detected by cardiac magnetic resonance imaging (CMR) in recovered individuals with non-hospitalized, milder cases of COVID-19.³ Of particular relevance, in a study of 26 US collegiate athletes recovered from COVID-19, CMR evidence of myocardial inflammation was observed in four (15%) athletes.⁴ These data, while limited due to the lack of appropriate controls, coupled with several publicized media reports of cardiac pathology in athletes, have fueled concerns of the impact of COVID-19 on the hearts of competitive athletes.

Because of these heightened concerns, a writing group of national sports cardiology experts (several who contributed to the initial expert consensus document¹) selected by the ACC's Sports & Exercise Cardiology Leadership Council, has now published updated consensus recommendations this week in JAMA Cardiology.⁵ Written in a question-and-answer format, the document provides important perspectives on the data that have emerged, while also factoring in the experience the authors have had on the ground in caring for athletes post-infection and guiding professional sporting organizations in their return to action plans. In addition to updated RTP algorithms, there are insightful discussions on the challenge of assessing myocardial injury in athletes, whether the concern for COVID-19-related myocardial injury warrants cancellation of sports seasons, and the pressing need for prospective registry data to help better inform future recommendations. Key points from the document are highlighted below.

The Role of CMR in the Evaluation of Athletes Post-COVID-19
Although recent CMR studies have received significant attention, the direct relevance to athletes is not fully clear. In the report by Puntmann et al., the cohort studied was older (mean age: 49 years) and had a higher comorbidity prevalence than a typical athlete population.³ Further, in the study from Rajpal et al., appropriate controls were lacking and a minority of athletes in the study had concerning symptoms, thus the clinical significance of isolated CMR abnormalities in the absence of high pre-test probability is unclear.

In this context, Kim and colleagues provide guidance on (1) which athletes should undergo CMR testing, and (2) how to integrate CMR findings into clinical management.⁵ With regard to (1), a CMR-based screening strategy for athletes with COVID-19 infection is not recommended at this time, citing insufficient data to support such a strategy as well as the requirement of having experienced centers perform and interpret parametric mapping techniques. Instead, it is recommended to reserve CMR for those athletes who present with a high pre-test probability of clinical myocarditis, which include typical symptoms (e.g., anginal chest pain, heart failure symptoms) and signs (e.g., elevated serum troponin, ischemic ECG changes, regional wall motion abnormalities), or if there are any concerning symptoms during a graded resumption in exercise training.

If an athlete presents with a clinical syndrome suggestive of myocarditis combined with CMR findings of myocardial inflammation, despite the lack of well-defined COVID-19 myocarditis pathophysiology, the myocarditis ACC/American Heart Association (AHA) RTP algorithm should be followed.⁶ However, if an athlete is found to have an isolated abnormal CMR finding, but low clinical pre-test probability of myocarditis, the authors state that the athlete should not be presumed to have COVID-19-related myocarditis. Instead, further risk stratification (e.g., exercise testing, ambulatory ECG monitoring) should be performed, and if normal, RTP may be reasonable with close follow-up.⁵

As more athletes are likely to undergo CMR testing after COVID-19 infection, these updated recommendations provide helpful guidance from experts on how to guide athletes through their recoveries and RTP. More data are needed to help refine these recommendations, and the authors comment on registries that are actively being constructed that will shed more light on the clinical utility of CMR in this setting.

Updated and Tailored RTP Guidance Algorithms
Building on the algorithm that was previously published,¹ the authors have now provided RTP algorithms tailored to three major athlete groups: (1) competitive high school athletes, (2) recreational Masters athletes, and (3) adult competitive athletes.⁵

In the high school athlete population, the authors report on their experience in evaluating the older high school athletes (≥15 years of age) and lack of observed cardiac pathology in those asymptomatic or with mild COVID-19 symptoms. For this group, further cardiovascular risk stratification is thought to be unnecessary. However, older high school athletes who develop moderate or cardiovascular symptoms should be managed according to the adult competitive athlete recommendations. Additionally, recognizing the rare subset of children who may develop multi-system inflammatory syndrome (MIS-C), close observation should continue for symptoms several weeks after infection.

For Masters and adult competitive athletes, the severity of initial infection remains an important factor in determining the RTP pathway, with no further cardiovascular risk stratification recommended for those who were asymptomatic or mildly symptomatic. The exception is that Masters athletes >65 years of age (particularly if cardiovascular comorbidities are present) and those with persistent symptoms should be considered for further risk stratification.

Navigating A New "Grey Zone"
Lastly, the authors emphasize the interesting point that increases in cardiovascular screening of athletes due to COVID-19 are leading to the emergence of a new "grey zone" in the evaluation of the athlete's heart. Biomarker elevations and isolated CMR findings that may be associated with COVID-19 infection can also be seen in the highly trained athlete. Ultimately, more robust data on the effects of COVID-19 infection on the myocardium are needed to better discriminate between the athlete's heart and myocardial injury. In the meantime, the writing group underscores that a shared decision-making approach is crucial in the context of guiding sports eligibility.

In summary, this updated expert consensus document provides helpful guidance for practitioners and organizations seeking to safely guide their athletes back into action after COVID-19 infection. It is strongly recommended reading for those who manage athletic patients, across the spectrum of age and level of competition, in this pandemic.

References

1. Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol 2020;May13:[Epub ahead of print].
2. Kim JH, Phelan DMJ. Poll: Return to Play in the Competitive Athlete Post COVID-19 Infection. http://www.acc.org. Sep 02, 2020. Accessed 10/18/2020. https://www.acc.org/latest-in-cardiology/articles/2020/09/02/08/55/poll-return-to-play-post-covid-19-infection.
3. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020;Jul 27:[Epub ahead of print].
4. Rajpal S, Tong MS, Borchers J, et al. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. JAMA Cardiol 2020;Sep 11:[Epub ahead of print].
5. Kim JH, Levine BD, Phelan DM, et al. Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return-to-play. JAMA Cardiol 2020;Oct 26:[Epub ahead of print].
6. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2362–71.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology

Keywords: Sports, Athletes, COVID-19, severe acute respiratory syndrome coronavirus 2, Coronavirus, Coronavirus Infections, American Heart Association, Myocarditis, Troponin, Consensus, Leadership, Cardiovascular Diseases, Follow-Up Studies, Risk Factors, Pandemics

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