Prolonged Symptoms Rare in College Athletes Following SARS-CoV-2 Infection, However, Exertional Chest Pain After Infection Warrants Further Evaluation

Up to 47% of adult non-athletes who develop COVID-19 and are not hospitalized experience prolonged symptoms (beyond three or four weeks). With regard to competitive collegiate athletes, Massachusetts General Hospital researchers have become the first to determine that the prevalence of prolonged COVID-19 symptoms is low but exertional symptoms on return to exercise could reflect dangerous underlying cardiopulmonary pathology.

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Bradley J. Petek, MD, cardiology fellow at Massachusetts General Hospital, Nathaniel Moulson, MD, and Aaron L. Baggish, MD, director of the Cardiovascular Performance Program, and colleagues detail the findings in the British Journal of Sports Medicine.

Study Methods

The data source for the study was the Outcomes Registry for Cardiac Conditions in Athletes, which is collecting data on U.S. college athletes returning to organized sports during the SARS-CoV-2 pandemic. This analysis covered the period September 1, 2020, to May 1, 2021, and included 3,597 athletes from 44 colleges/universities who represented 26 sports.

Persistent Symptoms

3,529 athletes had information available about symptom duration:

• 44 (1.2%) had symptoms lasting more than three weeks, usually isolated loss of taste/smell
• No athlete with persistent symptoms had abnormal results on triad testing (12-lead ECG, troponin and transthoracic echocardiogram)
• Only two athletes (0.06%) met the current definition of post-acute COVID-19 syndrome (symptoms for >12 weeks) on the last follow-up

Exertional Symptoms

3,393 athletes had information available about exertional symptoms:

• 137 (4%) reported exertional cardiopulmonary symptoms on return to exercise, most commonly shortness of breath, chest pain and/or exercise intolerance/fatigue
• 12 of the 137 (9%) had SARS-CoV-2–associated sequelae diagnosed on further clinical evaluation (cardiac involvement, n=5; pneumonia, n=2; inappropriate sinus tachycardia, n=2; postural tachycardia syndrome, n=2; pleural effusion, n=1)

Cardiac MRI

For 44 of the athletes with exertional symptoms, advanced diagnostic testing included cardiac MRI:

• 24 of these athletes had exertional symptoms including chest pain—Five (21%) had probable or definite SARS-CoV-2 cardiac involvement that included the pericardium in all cases; two athletes had myocardial involvement
• 20 athletes had exertional symptoms without chest pain—None were diagnosed with cardiac involvement

Guidance for Clinicians and Coaches

Athletes who have exertional cardiopulmonary symptoms on return to exercise after COVID-19 should have a thorough symptom-guided clinical evaluation. This is true even for athletes who had negative initial cardiac testing after the resolution of acute symptoms. Cardiac MRI should be considered for athletes with exertional chest pain.

This study suggests exertional chest pain on return to exercise presents a higher risk of SARS-CoV-2 cardiac involvement, but it is important not to discount other known clinical signs and symptoms of potential myocarditis.

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