Post-COVID Return to Play Guidance Evolves.

Athletes without cardiopulmonary symptoms after COVID-19 infection can gradually return to play without undergoing a battery of cardiac testing, according to the revised consensus statement[1] from the American College of Cardiology.

The new guidance replaces earlier informal recommendations released by leading sports medicine cardiologists in spring 2020[2] and fall 2020.[3] The first guidance document recommended triad testing, including an ECG, measurement of cardiac troponin, and an echocardiogram for all athletes after COVID-19 infection. The second iteration recommended triad testing only for patients with severe and worsening cardiac or COVID-19 symptoms.

The latest consensus statement is based on a virtual roundtable hosted by the American College of Cardiology in 2021 that included experts in myocarditis, long COVID, and sports cardiology who reviewed the evidence to date. “The [consensus statement] suggests using triad testing to evaluate athletes with cardiopulmonary symptoms after COVID-19 to determine which individuals may benefit from additional testing such as cardiac magnetic resonance imaging before returning to play,” said lead author of the consensus statement Ty J. Gluckman, MD, a clinical cardiologist and medical director at the Providence Heart Institute in Portland, in an interview. However, he noted that clinicians should still follow their judgment for individual patient decisions.

“Clinical judgment is paramount,” he said. “If someone is worried about myocarditis, they should make decisions they believe are best for their patients.”

Evolving Evidence

The evolving return-to-play after COVID-19 guidance reflects recent data on the potential implications of COVID-19 for athletes’ heart health. Viral infections are the most common cause of myocarditis, and data from early in the pandemic about the potential for myocardial injury in those with COVID-19 raised concerns about possible implications for athletes with COVID-19.[4]

“Myocarditis is a contributor to an increased risk of sudden cardiac death in athletes,” Gluckman explained. Early on in the pandemic, much concern existed about the potential risks posed by exercise in those with COVID-19.

“Because few data were available initially as to the potential myocardial risks with COVID-19, recommendations from the American College of Cardiology’s Sports and Exercise Cardiology Section published in the spring of 2020 were based on a very conservative approach,” Gluckman said. Some organizations, including the Big Ten collegiate athletic conference,[5] incorporated cardiac magnetic resonance imaging into their testing protocols for competitive athletes infected with SARS-CoV-2.

However, 2 registries, including ≈3800 athletes from North American professional sports leagues[6] and 42 colleges and universities,[7] found that the prevalence of clinical myocarditis after COVID-19 is between 0.6% and 0.7%. A third registry[8] of ≈1600 athletes in the Big Ten conference who underwent universal cardiac magnetic resonance imaging screening found that, although ≈2.3% had cardiac abnormalities, only ≈0.6% met the criteria for clinical myocarditis.

“The prevalence of clinical myocarditis was indeed quite low, and the presence of cardiopulmonary symptoms was predictive of cardiac involvement,” explained Jonathan H. Kim, MD, chief of sports cardiology and associate professor of medicine at Emory University. “That was the driving stimulus for saying screening should be driven by the presence of cardiopulmonary symptoms with COVID 19 infection or afterward.”

Gradual Return-to-Play

Cardiologists already use a similar symptom-based screening approach in athletes recovering from other viral infections that might contribute to heart complications, Kim said. The guidance also recommends a gradual return to exercise and monitoring for cardiopulmonary symptoms.

“There are always those rare cases where you may not have concerning symptoms upfront,” Kim explained.

Although the consensus statement is based on data from collegiate and professional athletes, Eugene Chung, MD, professor of internal medicine at the University of Michigan and chair of the American College of Cardiology’s Sports and Exercise Cardiology Leadership Council, said it should also apply to most athletes, including recreational ones. Although recreational athletes may not benefit from the same level of supervision as a collegiate or professional athlete, he said that recreational athletes can still apply a gradual return to exercise once COVID-19 symptoms have resolved. The consensus statement makes 1 exception, noting that players may resume activity before they regain lost taste or smell, symptoms that can take months to resolve.

“People should listen to their body and not accelerate if it doesn’t feel right,” Chung said.

The consensus statement also addresses the Centers for Disease Control and Prevention’s new recommendation for a 5-day quarantine after testing positive for COVID-19. “Asymptomatic athletes may return to exercise in 3 to 5 days,” noted Benjamin Levine, MD, professor of medicine at UT Southwestern and Director of Texas Health Dallas’s Institute for Exercise and Environmental Medicine. “However, because individuals may be infectious beyond 5 days, it is essential to avoid spreading the virus. For example, these individuals may want to train outside, use a mask or social distancing, or exercise alone until after the infectious period has passed.”

The consensus statement also addresses return-to-play in athletes who experience long-COVID or post-acute sequelae of SARS-CoV-2 infection (PASC) symptoms. They recommend reserving cardiac testing for individuals with PASC who either have cardiopulmonary symptoms or who had documented cardiac complications with COVID-19. Chung said that an individualized approach is vital because different people may recover at different rates.

“If PASC symptoms are relatively mild, it should be okay for the individual to start exercising,” Chung said. “They seem to hit a wall much sooner than expected and may have a prolonged recovery to get back to the level they expected. There does not seem to be a quick fix.”

The consensus statement suggests starting with recumbent exercises like cycling, rowing, or swimming for patients with PASC who have rapid heart rates, exercise intolerance, dizziness, or deconditioning. It also recommends starting with short 5- to 10-minute exercise durations, gradually increasing as their endurance improves. Chung said, “hydration, good nutrition, and sleep are also important.”

“Many questions remain about the potential cardiac complications of COVID-19 for athletes in the longer term and how they may compare with cardiac complications from other viral illnesses,” noted Levine. Chung said he hopes the registry data may eventually help clinicians predict athletes’ cardiac prognosis on the basis of cardiac testing. But in the meantime, Levine suggested ongoing monitoring of athletes for potential complications.

“We need to maintain a level of vigilance and make sure that we have systems in place like the [registry] of professional athletes and that we track these people carefully over time,” Levine said.