Return-to-Play Screening After COVID-19 for All Athletes

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In May 2020, the American College of Cardiology (ACC) published a consensus statement and algorithm in JAMA Cardiology to help clinicians determine when athletes can safely return to play (RTP) after recovery from COVID-19. Now that more experience and data have accumulated, the leaders of its Sports and Exercise Cardiology Section revised that statement.

Aaron L. Baggish, MD, director of the Cardiovascular Performance Program at Massachusetts General Hospital, is the senior author of the new guidance, also published in JAMA Cardiology. The statement now includes three algorithms for high school, masters and adult competitive athletes.

Asymptomatic and Mild COVID-19

The Centers for Disease Control and Prevention now recommends a self-isolation period of 10 days, not 14 days. Accordingly, the authors revised their recommendation about complete abstinence from exercise: 10 days from the date of the positive test result (in cases of asymptomatic COVID-19) or from the date of symptom onset (mild cases), regardless of the level of athletic competition.

Following asymptomatic or mild COVID-19, routine cardiovascular screening is unnecessary before RTP, but testing can be considered on an individual basis. Slow and carefully monitored resumption of activity is appropriate, and symptoms must have resolved completely.

Indications for Cardiac MRI

There is no widely accepted definition of clinically relevant myocardial injury secondary to COVID-19 infection among athletes. Cardiac MRI is appropriate for RTP determination when the athlete has a clinical syndrome suggestive of myocarditis plus:

• Isolated or combined objective pathologic criteria
• Recurrence of cardiovascular symptoms or new-onset exercise intolerance during the gradual resumption of physical activity

Athletes with isolated abnormal findings on cardiac MRI who had a low pretest probability of myocarditis should not be presumed to have myocardial injury attributable to COVID-19. Instead, they should be screened for inducible ventricular arrhythmias with maximal-effort exercise testing and extended ambulatory rhythm monitoring. If this additional testing is normal, RTP with close clinical monitoring is reasonable.

High School Athletes

High school athletes with systemic or cardiovascular symptoms during or after COVID-19 should be managed similarly to adult athletes in competitive sports (discussed in the article). They also need close observation for multisystem inflammatory syndrome (MIS-C).

If an adolescent athlete has recovered from MIS-C, the approach to risk screening should follow the original ACC algorithm for determining RTP after COVID-19.

Recreational Masters Athletes (>35 Years Old)

In general, routine RTP cardiovascular screening is not recommended for masters athletes because of the logistical infeasibility and expense coupled with the anticipated low risk of clinically significant cardiac injury.

However, masters athletes older than 65 may benefit from RTP screening, particularly those with pre-existing cardiovascular conditions and those with persistent symptoms.

Masters athletes who recovered from moderate to severe prior COVID-19 infection should be evaluated by a cardiologist before RTP.

Shared Decision-making

The promulgation of cardiovascular RTP screening is leading to more athletes with findings of unclear clinical relevance, such as mildly elevated cardiac troponin or nonspecific imaging abnormalities. Decisions about sports eligibility should strike a balance between the clinician's estimation of risk and the patient's tolerance for risk, with input from relevant stakeholders in the case of elite athletes.

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