Perspective:

This is an impressively large and detailed multicenter observational cohort of collegiate athletes. The prevalence of clinically identified cardiac involvement is similar to a recent study from multiple professional sports leagues.

The findings support recommendations outlined by experts from the ACC Sports and Exercise Cardiology section in October 2020: that is, asymptomatic or mildly symptomatic athletes fully recovered from COVID-19 infection do not require cardiac testing prior to returning to sport. For athletes with moderate or worse symptoms, and/or cardiopulmonary symptoms, cardiac evaluation inclusive of 12-lead ECG, troponin, and echo should be considered prior to return to play. CMR should also be considered based on clinical concern and testing results.

That said, the role of CMR remains unsettled. The authors chose to use “cardiac involvement” rather than “myocarditis” or “inflammation” or “injury.” This seems very reasonable, for while the CMR has emerged as the modality of choice for noninvasive assessment of myocarditis, its utilization remains nuanced. Access to CMR, acquisition and interpretation of images, and limited availability of normative data in athletes remain factors that must be taken into account. Of note, only about 11% of the study group underwent CMR, so the 3.0% “upper estimate” prevalence could be an underestimate. Additionally, this study does not address the impact of CMR abnormalities in asymptomatic subjects or the appropriate timing for follow-up CMR studies.

Limitations, as acknowledged by the authors, include heterogeneity of clinical assessments across the participating sites, reliance on testing result reports without core lab-type adjudication, and limited time of follow-up.