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

Abstract

ObjectivesQuantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports.DesignSystematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes.Data sourcesCombinations of key terms in Medline, Embase and Scopus (through 2 June 2021).Eligibility criteria for selecting studiesInclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age <18 or >64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists.ResultsIn total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%–15%, pericardial effusion 0%–58% and late gadolinium enhancement (LGE) 0%–46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%–4%) versus low scores (38%–42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities.Summary/conclusionAthletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.

Myocarditis in Athletes Recovering from COVID-19: A Systematic Review and Meta-Analysis

“…Finally, almost all studies assessed hs-TN levels, but none showed a correlation with the presence of cardiovascular abnormalities. This finding confirmed what was pointed out by a recent systematic review [ 11 ], thus confirming that hs-TN changes may be related to a broad set of clinical reason. A recent review [ 51 ] showed that normal ranges in athletes are still poorly defined, and further studies are needed to assess the normal TN value in athletes.…”

“…At the beginning of the pandemic, cases of myocarditis had been frequently described in hospitalized patients, but no information was available regarding cardiac involvement in athletes [ 5 ]. As assessed in a recent systematic review, several studies have subsequently investigated the possible cardiovascular complications of COVID-19 infection in young athletes [ 11 ]. This because myocarditis is recognized as a cause of sudden death in athletes [ 12 ].…”

Performance of Professional Soccer Players before and after COVID-19 Infection; Observational Study with an Emphasis on Graduated Return to Play

“…There are many important aspects of COVID-19 in sport, but given that the virus has emerged recently, practical knowledge is rather limited. Numerous studies have been published with the aim of giving instructions and guidelines on the treatment of athletes during and after infection [ 18 , 19 , 21 , 33 , 34 ]. As mentioned in the introduction, RTP protocols have been developed and were created based on prior knowledge of viral infections that attack the cardiorespiratory system [ 21 , 34 ].…”

“…Numerous studies have been published with the aim of giving instructions and guidelines on the treatment of athletes during and after infection [ 18 , 19 , 21 , 33 , 34 ]. As mentioned in the introduction, RTP protocols have been developed and were created based on prior knowledge of viral infections that attack the cardiorespiratory system [ 21 , 34 ]. However, there is a clear lack of research on concrete examples of infected athletes.…”

The benefit of vaccination against COVID-19 outweighs the potential risk of myocarditis and pericarditis

“…However, only 5 out of 1,597 athletes (0.3%) had both symptoms associated with myocarditis and abnormal laboratory (troponin level) and/or imaging findings (electrocardiography (ECG) and/or echocardiography) [ 18 ]. In a systematic review of CMR imaging studies performed in athletes with a history of COVID-19, the proportion of athletes with a confirmed diagnosis of myocarditis varied between 0% and 15% [ 19 ]. In the general population, data on the occurrence of subclinical myocarditis and pericarditis after COVID-19 are lacking.…”