In This Article
- Young and healthy athletes with COVID-19 with no or mild symptoms should refrain from exercise during their acute illness and quarantine, but may return to athletics in a gradual fashion without the need for additional cardiac testing
- For athletes with persistent symptoms after SARS-CoV-2 infection, thorough evaluation, further testing and delayed return to activity is recommended
- Sports Cardiologist Meagan Wasfy, MD, explains the importance of athletes who have had COVID-19 receiving specialized care, since the hearts of athletes will look different than the general population due to their exercise training
The Cardiovascular Performance Program in the Corrigan Minehan Heart Center at Massachusetts General Hospital has been treating athletes diagnosed with COVID-19. While many of these athletes have experienced asymptomatic or mild forms of the disease, for some, symptoms may persist, raising concern for cardiovascular injury.
In this Q&A, Meagan Wasfy, MD, sports cardiologist, describes the evolution of return-to-play guidelines as researchers uncover more about the progression and treatment of COVID-19, and the implications those findings have on the general patient population.
Q: What has it been like to treat athletes in the Cardiovascular Performance Program who have been diagnosed with COVID-19?
Wasfy: Many athletes diagnosed with COVID-19 in our program were diagnosed via screening tests through their team or college and have had no or mild symptoms. In these individuals, we have followed the evolving expert consensus guidelines from JAMA Cardiology and JACC on evaluating for COVID-19-related heart issues prior to returning to competitive athletics.
These "return to play" guidelines were developed due to early publications suggesting that the virus caused changes on cardiac imaging consistent with myocarditis in a sizable number of those infected, even if they only had mild disease. Because myocarditis is an important cause of sudden cardiac death during exercise, this caused a lot of concern regarding the safety of return to competitive athletics after COVID-19 infection.
For the most part, however, we have not found a high prevalence of heart issues in these athletes who by all other metrics have appeared to fare quite well through their infection. Based on our collective experience as a field, the newer guidelines published this fall suggest that young and otherwise healthy athletes with no or mild symptoms should refrain from exercise during their acute illness and quarantine, but may return to athletics in a gradual fashion without the need for additional cardiac testing. We do still evaluate for COVID-19 related heart issues prior to return to play in those athletes who have been hospitalized for COVID-19 or experienced, at the time of their acute illness, more moderate symptoms, especially those that are hard to disentangle from other cardiac symptoms such as chest tightness or shortness of breath.
A second group we have treated in our program are athletes with persistent symptoms after their COVID-19 infection. We approach these cases quite differently, and the evaluation is necessarily customized depending on what persistent symptoms the athlete is experiencing.
Fortunately, we have not found a high prevalence of serious cardiovascular issues such myocarditis or pulmonary embolism, even in athletes with persistent symptoms like exercise intolerance, chest pain or excessive shortness of breath that could be consistent with these diagnoses. Because we remain uncertain about the true prevalence of clinically meaningful cardiovascular sequelae of COVID-19, a thorough evaluation in those patients with suggestive symptoms is still warranted.
More commonly we have identified other diagnoses such as mild reactive airway disease or autonomic dysfunction as a cause for symptoms. Though viral infection is known to be a trigger for both entities, it remains to be seen if they are more common after COVID-19 than other viruses.
Finally, in some cases, despite thorough testing, we haven't found any cause for persistent symptoms, suggesting we still have a lot to learn about the recovery from COVID-19 and any long-term health impacts.
Q: What do we currently know about the risk of cardiovascular damage in athletes who have been diagnosed with COVID-19?
Wasfy: First, stepping back from athletes, we know that signs of cardiac injury, such as elevated blood levels of troponin, are common among patients hospitalized due to COVID-19, and those with signs of cardiac injury have a worse prognosis. This led to research studies using cardiac imaging (like MRI) to evaluate for myocarditis in patients who have had COVID-19 because myocarditis is known to be a sequela of other common viral illnesses. These studies, including one performed in young athletes, identified a high prevalence of potentially abnormal MRI findings, but are to be interpreted with caution.
First, we do not have data in the athlete population to define the distribution of normal MRI findings. Some of the "abnormal" MRI findings described in young athletes may have existed prior to the COVID-19 infection.
Second, we do not know whether the abnormal MRI findings identified in these studies represent myocarditis. In most instances in the published studies, these MRI findings were not accompanied by the additional features (chest pain symptoms, abnormal electrocardiogram, abnormal troponin levels) that we typically use to make a clinical diagnosis of viral myocarditis, and could instead represent a less specific form of post-viral injury that we've never identified before because we have not scrutinized the hearts of athletes after other common viral respiratory illnesses.
Because we do not yet know if these findings on cardiac imaging after COVID-19 carry with them the same risk of sudden cardiac death as myocarditis, we advocate a conservative approach. Presuming the MRI is high quality and read by an imager who understands the expected findings for an athlete's heart, if the imaging meets the criteria for myocarditis, we follow our expert consensus guidelines for myocarditis that pre-dated COVID-19. These include a period of 3-6 months off from the competitive sport to allow for resolution.
Until we have more data, a balanced perspective is appropriate—like the rest of the population, athletes should continue to take precautions to prevent exposure to COVID-19 both from a public health perspective and because of the uncertain outcomes from the illness.
At the same time, the majority of young and otherwise healthy athletes will not suffer serious cardiovascular issues from the virus, and our hard work as a sports cardiology community will be optimizing our protocols to identify the few athletes that do require our attention after COVID-19 illness.
The main determinant as to whether sports seasons should be canceled at this stage should not be the safety of return to play after COVID-19 infection, but rather the impact that sports might have on increasing overall community transmission.
Q: What implications do these findings have for the wider patient population?
Wasfy: The issue of whether COVID-19 impacts the cardiovascular system is one that is relevant to all patients. One important concept from the return to play guidelines is refraining from heavy exertion for all patients during the course of their COVID-19 illness. The cardiovascular system, even if not directly impacted by the virus, is not immune to the higher levels of inflammation and prothrombotic state throughout the body that accompanies COVID-19. We have no data to prove this suspicion, but adding exercise as a stressor during and immediately after the acute illness could potentially increase the risk of a sudden and unexpected event, like arrhythmia or heart attack, during exercise.
So, we advocate that all patients take a period of time for rest and lighter activity during their quarantine for COVID-19 (10 days from positive test and/or symptom onset). Those who have no or mild symptoms may consider resuming their usual exercise in a gradual fashion after this period is up. Those with moderate or severe COVID-19 illness, particularly those who were hospitalized, had chest symptoms such as shortness of breath or chest tightness or have pre-existing cardiovascular diagnoses, should consider keeping activity light for an additional 10 days after their COVID-19 symptoms resolve. If patients experience recurrence of symptoms or new symptoms in returning to exercise after COVID-19, they should refrain from further exercise and consult with their physicians.
Q: When should a patient diagnosed or recovered from COVID-19 seek out the assistance of a program like the Cardiovascular Performance Program at Mass General?
Wasfy: We primarily evaluate athletes, which broadly includes individuals who place a high premium on training, competition and sports achievement. Our patients range from young athletes participating in competitive organized sports to post-collegiate masters athletes who are highly active in their sport but may not compete. Prior to resuming their sport, athletes should seek cardiology evaluation after COVID-19 illness that is moderate or greater in severity during the acute illness, which we define as persistent fevers, chills, lethargy or any shortness of breath or chest tightness during the first 10-14 days of infection or anyone that has required hospitalization. In most instances, this evaluation will include cardiac testing such as an ECG, blood troponin level and echocardiogram. Though these are all widely available tests, it is important they are interpreted by physicians like those in our group who are accustomed to evaluating what constitutes a normal result for an athlete, since their hearts will look different than the general population due to their exercise training.
Athletes should also seek medical evaluation if during the gradual resumption of exercise after their acute illness they find they have any new symptoms suggestive of cardiovascular origin. This includes shortness of breath, chest tightness, lightheadedness, palpitations, syncope or reduced ability to exercise beyond what they might expect from the time off from exercise that they took during their illness. The evaluation of these cases can be challenging, and we are happy to help guide the evaluation of active patients and athletes who are struggling in this regard.
Q: What is the additional research you'd like to see on this topic moving forward?
Wasfy: Registry-based work to better define the prevalence of myocarditis in athletes in the National Collegiate Athletic Association who have had COVID-19 is ongoing, and will help us to further refine the protocols for cardiac testing and to identify if there are signals for short to intermediate term risk of sudden cardiac arrest or other important cardiovascular outcomes in those athletes who have had COVID-19. We also look forward to more data about how to best support and rehabilitate active patients who are struggling with exercise-related symptoms after the acute phase of COVID-19.
Learn more about the Cardiovascular Performance Program
Refer a patient to the Corrigan Minehan Heart Center