This report is intended to address common issues regarding coronavirus disease 2019 (COVID-19) and cardiac pathology among competitive athletes, including recommendations regarding return to play. The following are key points to remember:

1. There is a high prevalence (>20%) of cardiac injury among patients hospitalized with moderate or severe COVID-19. However, the pathogenesis of myocardial injury is variable, with inconsistent evidence of direct myocyte viral invasion.
2. There is no widely accepted definition of what constitutes clinically relevant myocardial injury secondary to COVID-19 infection among competitive athletes; some abnormalities that can be associated with myocardial injury can overlap with normal findings attributed to the athlete’s heart, including transient troponin elevation and mildly reduced left ventricular ejection fraction (LVEF).
3. Data from cardiac magnetic resonance (CMR) imaging suggest that cardiac pathology may be present in some people with COVID-19 of only mild or moderate severity. However, in the absence of symptoms suggestive of myocarditis, CMR imaging is not recommended in athletes based solely on documented or suspected infection.
4. Concerns about the implications of cardiac injury attributable to COVID-19 should not constitute primary justification to cancel or delay sports. Rather, this decision should be driven by the need to limit viral spread.
5. The authors make the following recommendations for cardiovascular considerations for return to play for athletes:

Among athletes with prior COVID-19 infection but who remain entirely asymptomatic, and following the US Centers for Disease Control and Prevention (CDC) guidelines for self-isolation, the authors do not advocate cardiovascular risk stratification before returning to play.

For high school athletes <15 years old who are recovering from moderate or severe COVID-19 infection, out of concern for the rare occurrence of a multisystem inflammatory syndrome (MIS-C), the authors recommend formal evaluation with general pediatrics or pediatric cardiology prior to returning to play in order to assess the need for cardiovascular risk stratification.

For high school students ≥15 years old without systemic symptoms or persistent cardiovascular complaints during COVID-19 infection, and after following CDC guidelines for self-isolation, the authors recommend that further cardiovascular risk stratification is not necessary. However, if there were systemic or cardiovascular symptoms during or after infection, then the authors recommend an approach similar to athletes of older ages, and close observation for MIS-C.

Among masters-level athletes with mild COVID-19 infection, taking into account the required logistics and low anticipated risk of clinically significant cardiac injury, the authors counsel against routine cardiovascular screening. However, masters-level athletes should be evaluated by a cardiologist following moderate to severe COVID-19 infection; and athletes >65 years and those with pre-existing cardiovascular conditions (hypertension, diabetes, coronary artery disease, atrial fibrillation) or with persistent symptoms may benefit from risk stratification prior to returning to play.

In parallel with CDC guidelines reducing self-isolation from 14 days to 10 days from the time of documented infection, the authors recommend exercise abstinence for 10 days from the date of the first positive test result in athletes with asymptomatic COVID-19 infection, followed by a slow and carefully monitored return to activity.

The authors do not recommend cardiac risk stratification for competitive athletes with mild, self-limited disease prior to returning to play. However, cardiovascular risk stratification should be considered for patients with protracted symptoms (≥10 days).

Comprehensive cardiovascular risk stratification should be done prior to return to play for athletes with prior moderate or severe COVID-19 infection.

When performed, testing should include clinical evaluation, ECG, high-sensitivity troponin, and echocardiography. If baseline tests are abnormal, if symptoms persist or recur, or in the setting of cardiogenic syncope, then additional testing can include CMR, exercise testing, and extended ambulatory rhythm monitoring.

If cardiac involvement is diagnosed, then return to play recommendations should be based on current myocarditis guidelines.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Hypertension, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and Imaging

Keywords: Adolescent, Athletes, Atrial Fibrillation, Coronavirus, COVID-19, Echocardiography, Electrocardiography, Exercise, Heart Failure, Hypertension, Magnetic Resonance Imaging, Myocarditis, Pathology, Primary Prevention, Risk Factors, Severe Acute Respiratory Syndrome, Sports, Syncope, Troponin, Ventricular Function, Left

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