College Athletes Unlikely to Have Cardiac Complications from SARS-CoV-2 Infection
Key findings
- This prospective registry study determined the prevalence of cardiac involvement in 3,018 collegiate athletes diagnosed with asymptomatic SARS-CoV-2 infection or mild to severe COVID-19
- Of 2,820 athletes screened with ECG, troponin and/or echocardiography, 119 had at least one abnormal result and underwent cardiac MRI; of those, 15 (0.5% of the entire cohort) were judged to have definite, probable or possible cardiac involvement
- The other 198 athletes had cardiac MRI performed as part of primary screening, regardless of symptom burden or the results of other testing; six of them (3.0%) had definite, probable or possible cardiac involvement
- None of the 21 athletes diagnosed with definite, probable or possible cardiac involvement had an adverse cardiac event during short-term follow-up (median 130 days)
- In general, these results support current guidelines for return-to-play cardiac testing
The new Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) was created by the American Heart Association and the American Medical Society for Sports Medicine to investigate the prevalence and clinical outcomes of cardiovascular disease, including cardiac involvement after SARS-CoV-2 infection, in NCAA athletes.
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Nathaniel Moulson, MD, former research fellow at Massachusetts General Hospital, and Aaron L. Baggish, MD, director of the Cardiovascular Performance Program, serve on the ORCCA Steering Committee. In Circulation, they and their colleagues present encouraging results from the first analysis of data, which generally supports the current cardiac testing guidelines for return to play after SARS-CoV-2 infection.
Study Methods
The data analyzed were collected from 42 colleges and universities between September 1 and December 31, 2020. The 3,018 athletes (32% female) who were included represented 26 sports, predominantly football (36%), baseball (9%) and cross country/track and field.
After testing positive for asymptomatic SARS-CoV-2 infection or recovering from COVID-19, the athletes underwent cardiac testing to determine cardiac involvement as determined by their institution. Mass General served as the central data collection center.
"Triad Component" Screening
2,820 athletes were initially screened with electrocardiography, cardiac troponin assay and/or transthoracic echocardiography, including 2,231 who were screened with all three. 119 of them later underwent cardiac magnetic resonance (CMR) imaging because of at least one abnormal initial result. Of those, 15 (0.5% of the entire cohort) were judged to have definite, probable or possible myocardial or myopericardial involvement.
CMR-Inclusive Screening
The other 198 athletes had CMR performed as part of the primary screening, regardless of symptom burden or the results of other testing. Six of them (3.0%) had definite, probable or possible cardiac involvement, including three (1.5%) who had definite or probable involvement.
Altogether, 21 athletes (0.7%) had definite, probable or possible cardiac involvement.
Predictors of Cardiac Involvement
On multivariable analysis, after adjusting for sex and race, significant predictors of cardiac involvement were:
- Cardiopulmonary symptoms during COVID-19 or on return to exercise (OR, 3.1)
- Abnormal results on ECG, troponin, echocardiography or any combination (OR, 37.4)
Outcomes
The 21 athletes with definite, probable or possible cardiac involvement—No adverse cardiac events (new clinically significant arrhythmias, clinical heart failure, sudden cardiac arrest or sudden death) or hospitalizations were reported over a median follow-up period of 130 days.
Entire cohort—One event (successfully resuscitated sudden cardiac arrest) occurred over a median follow-up period of 113 days. This athlete had undergone CMR 17 days after onset of COVID-19 symptoms without findings suggesting acute cardiac involvement, so the event was probably unrelated to SARS-CoV-2 infection.
Return-to-Play Testing
82% of athletes diagnosed with definite or probable cardiac involvement in this study would have been identified by a stepwise approach that used the presence of moderate to severe cardiopulmonary symptoms or any abnormal initial test to trigger CMR. The study supports the following approach to the return-to-play cardiac screening of collegiate athletes:
- Athletes with asymptomatic SARS-CoV-2 infection or mildly symptomatic COVID-19 do not require additional cardiac testing prior to resumption of organized athletics
- "Triad" testing (12-lead ECG, troponin assay and echocardiography) should be considered for athletes who experience moderate to severe systemic and/or cardiopulmonary symptoms (cardiopulmonary symptoms are a particularly important risk marker)
- The diagnostic yield of CMR will be optimized by confining its use to athletes who have cardiopulmonary symptoms and/or abnormalities on triad testing
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