Recommendations for clinicians charged with determining when competitive athletes and highly active individuals who have had COVID-19 and recovered are medically appropriate to return to play were discussed in an opinion piece published in JAMA Cardiology.
Unfortunately, there are limited data available to establish epidemiologic and clinical metrics to facilitate this process. The prevalence of asymptomatic COVID-19 cases in the community and of cardiac injury among nonhospitalized individuals with COVID-19 is still unclear, as are long-term outcomes attributable to COVID-19 cardiac injury. While acknowledging these limitations, members of the American College of Cardiology’s Sports & Exercise Cardiology Council, with input from national leaders in sports cardiology, provided a consensus expert opinion clinical framework on return to play in the era of COVID-19. The recommendations are exclusive to cardiovascular considerations, and concomitant pulmonary limitations also require consideration. The council members place “an emphasis on the temporal progression of confirmed infection and have incorporated time-based benchmarks in our recommendations.”
Asymptomatic athletes and those who tested negative for COVID-19 are permitted to resume training without additional testing, but those who are asymptomatic with a positive test (active infection) “should refrain from exercise training for at least 2 weeks from the date of positive test result and follow strict isolation guidelines.” If they remain asymptomatic, slow resumption of activity should be guided by the direction of their medical professional. Asymptomatic individuals with detected COVID-19 antibodies in response to previous infection are recommend to undergo evaluation similar to that advised for asymptomatic athletes with positive COVID-19 test results, and cardiac testing should be considered if there is concern for cardiac involvement.
Athletes with mild symptoms and testing positive for COVID-19 are recommended to adhere to a minimum of 2 weeks’ cessation of any exercise training following symptom resolution as there is a need to consider the possibility of cardiac injury among nonhospitalized COVID-19 patients. A careful clinical cardiovascular evaluation in combination with cardiac biomarkers and imaging should be considered for recovered individuals ready to resume training after the recommended temporal restrictions. Depending on clinical course and initial tests, further adjunctive testing with cardiac magnetic resonance imaging, exercise testing, or ambulatory rhythm monitoring can be considered. Return to exercise with close clinical follow-up is considered reasonable for individuals with no symptoms and no objective evidence of cardiac involvement. However, “if testing suggests cardiac involvement, return to play should be based on myocarditis return-to-play guidelines.”
For previously hospitalized or more severely ill patients, following myocarditis return-to-play recommendations is recommended for this higher-risk cohort. If cardiac biomarkers and imaging studies are normal, a minimum of 2 weeks’ rest after symptom resolution before undergoing careful clinical cardiovascular evaluation with consideration of repeated cardiac testing, followed by a graded resumption of exercise is recommended.
The authors highlight that “…resumption of intense exercise training and competition requires careful consideration of the severity of prior infection and the likelihood of cardiovascular involvement.” They further acknowledge that the approaches outlined are conservative and subject to change due to the clinical uncertainty surrounding the prevalence and magnitude of postinfection complications. They also emphasize “the critical need for widespread antigen testing, the development and dissemination of antibody testing, and ultimately vaccination to prevent disease.”
Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection [published online May 13, 2020]. JAMA Cardiol. doi:10.1001/jamacardio.2020.2136