Cardiovascular Evaluation After COVID-19 in 137 Collegiate Athletes: Results of an Algorithm-Guided Screening

Abstract

Concerns for cardiovascular sequelae of coronavirus disease 2019 (COVID-19), including myocardial injury or myocarditis, brought about recommendations for evaluating athletes after infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1 Assessments that were based on symptoms, disease severity, and cardiovascular testing were refined to guide decision making and safe return to play in various groups. 2 However, cardiac magnetic resonance (CMR) findings of myocarditis in athletes have ranged from as high as 15% (4 out of 26 athletes in one study) to as low as 1.4% (2 out of 145 athletes in another study), many of whom had no or only mild symptoms, have raised concerns around testing in this population. 3,4 CMR is a recognized tool for diagnosing myocarditis yet is not generally recommended for athletes after COVID-19 without an elevated index of suspicion. 2,5 Given limited data in competitive athletes after infection with SARS-CoV-2, we report our initial experience with an algorithmguided screening of collegiate athletes and intermediate-term follow-up.Collegiate athletes were evaluated in sports cardiology clinic no sooner than 10 days after testing positive for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. A 12-lead ECG, transthoracic echocardiogram, and conventional cardiac troponin I (cTn) level were obtained from all athletes regardless of symptom history or illness severity. Anyone with an abnormal test result or clinical evaluation of concern was referred for CMR. Those with normal evaluations and negative testing results or negative CMR were returned to full participation after a graduated reintroduction of exercise. Clinical follow-up occurred through communication with university athletic staff. The study was approved by the University of Tennessee Institutional Review Board. The data will be made available on reasonable request.We evaluated 137 athletes from July 9, 2020, to October 21, 2020. Athletes were young adults (median, 20 years; range, 18-27 years), majority male (n=93, 68%), and of various racial/ethnic backgrounds (Black, n=66, 48%; White, n=65, 47%; Hispanic, n=10, 7%). Median time to evaluation was 16 days (interquartile range, 12-34). A broad range of athletics was represented: football (n=51, 37%), dance (n=18, 13%), basketball (n=16, 12%), baseball (n=13, 10%), tennis (n=8, 6%), softball (n=7, 5%), soccer (n=7, 5%), cheer (n=6, 4%), track (n=5, 4%), volleyball (n=4, 3%), and golf (n=2, 1%). Students represented 3 universities and competed across National Collegiate Athletic Association Divisions 1 (majority), 2, and 3.Most athletes were symptomatic (n=112, 82%) and experienced only mild (n=75, 67%) or moderate (n=37, 33%) symptoms. The most frequent symptoms were loss of smell/taste (n=65, 58%), fever (<2 days, n=47, 42%), headache (n=46, 41%), and fatigue (n=45, 40%). Less frequently, shortness of breath (n=14, 12%) and chest pain/tightness (n=13, 11%) were reported. Black and Cardiovascular Evaluation After COVID-19 in 137 Collegiat...

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

“…In a hierarchical clustering analysis, these groups were associated with GLS <−16% on echocardiography. Furthermore, Hendrickson et al 31 reported only a trace of PE in 4 (2.9%) athletes, with further normal evaluations. Gervasi et al 24 reported no significant differences between COVID-19 positive soccer players and COVID-19 negative soccer players for LVEF (p=0.55) and TAPSE (p=0.69).…”

“…studies, ranging from no myocardial involvement (Vago et al) to 15% (Rajpal et al26 ). Hendrickson et al31 reported CMR findings in only five athletes, with no abnormal findings detected by CMR.…”

Cardiovascular Magnetic Resonance for Patients With COVID-19

“…However only a small fraction of the professional athletes underwent CMR. Hendrickson et al ( 59 ) evaluated 137 collegiate athletes, with 5 patients referred for CMR because of abnormal testing results (eg, elevated cTn, coronary artery ectasia [ 59 ]). No abnormal findings were detected by CMR, and no athlete had an abnormal ECG.…”

Return to Play for Athletes After COVID-19 Infection

“…Total Rajpal et al 2 Vago et al 4 Małek et al 5 Starekova et al 6 Clark et al 7 Martinez et al 8 Moulson et al 9 Hendrickson et al 10 Hence, the rapid evolution of data in this area continues to support the idea that the more practical and more widely available approach of testing with ECG, echocardiography, and serum troponin likely improves specificity and decreases burden of potentially unwarranted athletic restriction. The data in the article by Daniels et al 11 elevate our ability to intelligently discuss the issues with athletes, their families, coaches, performance coaches, trainers, sports scientists, and institutions, among the many stakeholders involved in the well-being of athletes within the universe of organized sports.…”

“…Both the Kim et al report 1 and our Editorial 3 at the time called for larger data sets, so that recommendations could be refined and more informed by data.In only 6 months since then, there has been a remarkable amount of information acquired, analyzed, and published regarding post-COVID-19 prevalence of cardiac abnormalities in athletes, as summarized in the Table. 2,[4][5][6][7][8][9][10][11] In a recent study of 789 professional athletes, screening consisted of serum troponin testing, ECG, and echocardiography, regardless of symptoms. 8 Thirty of these athletes (3.8%) had abnormal test results resulting in referral for CMR imaging, with 3 diagnosed with myocarditis.…”