A prospective study on the consequences of SARS-CoV-2 infection on the heart of young adult competitive athletes: Implications for a safe return-to-play

Abstract

Objectives The COVID-19 pandemic has shocked the sports world because of the suspension of competitions and the spread of SARS-CoV-2 among athletes. After SARS-CoV-2 infection, cardio-pulmonary complications can occur and, before the resumption of sports competitions, a screening has been recommended. However, few data are available and discrepancies exist in the screening modalities. We conducted this prospective study to investigate the incidence of cardiovascular consequences following SARS-CoV-2 infection in young adult competitive athletes and the appropriate screening strategies for a safe return-to-play. Methods Ninety competitive athletes (24 ± 10 years) after asymptomatic or mildly symptomatic SARS-CoV-2 infection were screened by physical examination, blood testing, spirometry, 12‑lead resting ECG, 24-h ambulatory ECG monitoring, echocardiogram, and cardiopulmonary exercise testing (CPET). Results Sixty-four athletes (71.1%) were male, and most (76.7%) were mildly symptomatic. After SARS-CoV-2 infection, spirometry and resting ECG were normal in all athletes. Ambulatory ECG monitoring demonstrated <50/24 h supraventricular and ventricular premature beats in 53.3% and 52.2% of athletes, respectively, in the absence of malignant arrhythmias. CPET did not demonstrate cardiopulmonary limitations. Echocardiography showed pericardial effusion in 3 athletes (all females) with symptomatic SARS-CoV-2 infection (3.3%; 4.4% in the symptomatic group) with a definitive diagnosis of myopericarditis in 1 athlete (1.1%) and pericarditis in 2 athletes (2.2%). Conclusions Cardiac consequences of SARS-CoV-2 infection were found in 3.3% of competitive athletes. An appropriate screening primarily based on the detection of uncommon arrhythmias and cardiac symptoms should be recommended in competitive athletes after SARS-CoV-2 infection to detect a cardiac involvement and guarantee a safe return-to-play.

Cardiac abnormalities in athletes after SARS-CoV-2 infection: a systematic review

“…In five studies comprising 268 athletes including study controls CMR was performed; in three studies comprising 897 athletes including study controls echocardiography was performed; in four studies comprising 1968 athletes including study controls both CMR and echocardiography were performed. COVID-19 was diagnosed by real-time reverse transcriptase PCR in seven studies, by antibody testing in two studies and in two studies by one of the two; one study (Cavigli et al 23 ) study did not report diagnostic tests. All included athletes had recovered from SARS-CoV-2 infection, of which 0.1% recovered in-hospital and 99.9% at home.…”

“…Additionally, Martinez et al, 35 reported six cases of pericarditis/myocarditis (confirmed on CMR) of which four had abnormal echocardiography findings ('small' (not further defined) PE, LVEF 50%, new region wall abnormalities/preserved LVEF and dilated RV). Finally, Cavigli et al 23 reported PE in three athletes with symptomatic SARS-CoV-2 infections, of which one confirmed myopericarditis and two cases of pericarditis.…”

Return to Play after SARS-CoV-2 Infection in Competitive Athletes of Distinct Sport Disciplines in Italy: A FMSI (Italian Federation of Sports Medicine) Study

“…In these athletes, RTP was also more delayed in comparison to those with cardiac abnormalities but without arrhythmias. Surprisingly, few small studies [6] included ET as mandatory in the screening for RTP after SARS-CoV-2 infection, despite it being well known that effort may unmask arrhythmias not present at rest [11]. Additionally, exercise stress testing (e.g., step test) is a fundamental component of the annual pre-participating screening in competitive and professional athletes in Italy, according to FMSI rules approved by the Italian law.…”

“…A number of studies have aimed to determine cardiac risk stratification in athletes over the last two years of the pandemic [2][3][4][5][6][7][8]. However, the relatively small sample sizes of the studies, the single-centered approach, the small number of sport disciplines assessed and the underrepresentation of female athletes limit definitive conclusions and the generalizability of the results obtained to date.…”

The Impact of COVID-19 on the Preparation for the Tokyo Olympics: A Comprehensive Performance Assessment of Top Swimmers

“…In a study by Italian researchers, ninety asymptomatic or mildly symptomatic competitive athletes were involved in different sports. Cardiac consequences of COVID-19 infection were investigated by detailed cardiovascular screening (physical examination, blood tests, spirometry, 12-lead resting ECG, 24-h ambulatory ECG monitoring, echocardiography, CPET) [ 25 ]. Perimyocarditis was found in one case and pericarditis in two cases, instances which are as low as in our study.…”