Few cases of inflammatory heart disease were detected in cardiac screening of athletes who recovered from COVID-19, according to a study published in JAMA Cardiology.
The study used data from professional sports leagues, all of which implemented a conservative return to play (RTP) cardiac testing program aligned with the American College of Cardiology recommendations.
This cross-sectional study included 789 professional athletes who tested positive for COVID-19 with a mean age of 25 years (SD, 3). Of the study participants, 777 were men. A total of 460 participants (58.3%) were symptomatic, and 329 (41.7%) were either asymptomatic or minimally symptomatic. No cases were deemed severe, and no athletes were hospitalized with cardiopulmonary symptoms, while 1 athlete spent a night in hospital for observation.
The RTP protocol required troponin testing, electrocardiography (ECG), and resting echocardiography for every positive test. Abnormal test results were referred for further testing, which included cardiac magnetic resonance (CMR) imaging and/or stress echocardiography.
Abnormal troponin levels, defined as a level greater than the 99th percentile of the upper limit of normal, were observed in 6 athletes (0.8%). ECG abnormalities warranting further testing occurred in 10 athletes (1.3%), and 20 (2.5%) had an echocardiographic finding requiring testing to exclude acute cardiac injury. Of these 30 (3.8%) requiring further screening, 27 (90.0%) received CMR imaging. Downstream testing confirmed inflammatory heart disease in 5(18.5%; 0.6% of the total cohort). CMR imaging also confirmed 3 athletes (0.4% of the total cohort) with myocarditis and 2 (0.3% of the total cohort) with pericarditis.
This study was limited in that screenings and testing were carried out by teams of doctors and cardiologists from all over the United States and Canada, meaning the determinations in cases, and needs for downstream testing, varied. The results are also limited in that CMR imaging was not uniformly part of initial screens. Therefore, subclinical cases of inflammatory heart disease may have been missed.
Time to testing also varied, and some early manifestations of cardiac injury may have been missed. Finally, nearly all study participants were men and this, along with the decentralized nature of the process across leagues and variations in interpretations, limits the ability to provide a uniform criterion for diagnosing COVID-19-related inflammatory heart disease.
Investigators were able to conclude that in athletes with prior COVID-19 infection, potential cardiac involvement was rare. Imaging evidence of inflammatory heart disease resulting in a restriction from play occurred in only 0.6% of study participants. While not generalizable to all athletic populations, the success of this expert consensus RTP screening protocol provides clinical guidance to other organizations, said investigators.
Long-term follow-up is ongoing and investigators acknowledge the need for longitudinal assessments of other athlete populations to better understand the potential short and long-term consequences of COVID-19 infection.
Several authors report consulting and personal fees from several of the leagues, associations and teams involved. For full disclosure details please refer to the original reference.
Martinez MW, Tucker AM, Bloom OJ, et al. Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening. Published online March 4, 2021. JAMA Cardiol. doi: 10.1001/jamacardio.2021.0565