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Observational Study
. 2021 Jul 27;144(4):256-266.
doi: 10.1161/CIRCULATIONAHA.121.054824. Epub 2021 Apr 17.

SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes

Collaborators, Affiliations
Observational Study

SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes

Nathaniel Moulson et al. Circulation. .

Abstract

Background: Cardiac involvement among hospitalized patients with severe coronavirus disease 2019 (COVID-19) is common and associated with adverse outcomes. This study aimed to determine the prevalence and clinical implications of COVID-19 cardiac involvement in young competitive athletes.

Methods: In this prospective, multicenter, observational cohort study with data from 42 colleges and universities, we assessed the prevalence, clinical characteristics, and outcomes of COVID-19 cardiac involvement among collegiate athletes in the United States. Data were collected from September 1, 2020, to December 31, 2020. The primary outcome was the prevalence of definite, probable, or possible COVID-19 cardiac involvement based on imaging definitions adapted from the Updated Lake Louise Imaging Criteria. Secondary outcomes included the diagnostic yield of cardiac testing, predictors for cardiac involvement, and adverse cardiovascular events or hospitalizations.

Results: Among 19 378 athletes tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 3018 (mean age, 20 years [SD, 1 year]; 32% female) tested positive and underwent cardiac evaluation. A total of 2820 athletes underwent at least 1 element of cardiac triad testing (12-lead ECG, troponin, transthoracic echocardiography) followed by cardiac magnetic resonance imaging (CMR) if clinically indicated. In contrast, primary screening CMR was performed in 198 athletes. Abnormal findings suggestive of SARS-CoV-2 cardiac involvement were detected by ECG (21 of 2999 [0.7%]), cardiac troponin (24 of 2719 [0.9%]), and transthoracic echocardiography (24 of 2556 [0.9%]). Definite, probable, or possible SARS-CoV-2 cardiac involvement was identified in 21 of 3018 (0.7%) athletes, including 15 of 2820 (0.5%) who underwent clinically indicated CMR (n=119) and 6 of 198 (3.0%) who underwent primary screening CMR. Accordingly, the diagnostic yield of CMR for SARS-CoV-2 cardiac involvement was 4.2 times higher for a clinically indicated CMR (15 of 119 [12.6%]) versus a primary screening CMR (6 of 198 [3.0%]). After adjustment for race and sex, predictors of SARS-CoV-2 cardiac involvement included cardiopulmonary symptoms (odds ratio, 3.1 [95% CI, 1.2, 7.7]) or at least 1 abnormal triad test result (odds ratio, 37.4 [95% CI, 13.3, 105.3]). Five (0.2%) athletes required hospitalization for noncardiac complications of COVID-19. During clinical surveillance (median follow-up, 113 days [interquartile range=90 146]), there was 1 (0.03%) adverse cardiac event, likely unrelated to SARS-CoV-2 infection.

Conclusions: SARS-CoV-2 infection among young competitive athletes is associated with a low prevalence of cardiac involvement and a low risk of clinical events in short-term follow-up.

Keywords: COVID-19; SARS-CoV-2; athletes; myocarditis; return to sport.

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Figures

Figure 1.
Figure 1.
Prevalence of initial symptoms in athletes with symptomatic SARS-CoV-2 infection. Maroon bars indicate cardiopulmonary symptoms. *Athletes with known initial symptoms. COVID indicates coronavirus disease; SARS-COV-2, severe acute respiratory syndrome coronavirus 2; and SOB, shortness of breath.
Figure 2.
Figure 2.
Time from initial infection to cardiac testing. *Time from initial infection calculated as the longest time from date of initial symptom onset or date of positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to date of cardiac test. The total athletes with known time frame were as follows: cardiac magnetic resonance imaging (CMR), n=302; ECG, n=2765; troponin (Trop), n=2537; and transthoracic echocardiography (TTE), n=2406. Midline is the median; box, interquartile range (IQR); whiskers, 95% CI.
Figure 3.
Figure 3.
Results of primary CMR versus clinically indicated CMR screening protocols. A, Athletes undergoing primary CMR screening protocol. B, Athletes undergoing clinically indicated CMR screening protocol. *Borderline triad testing as indication for CMR included detectable troponin level but not >99th percentile, nonspecific ECG abnormalities not fulfilling international criteria, and transthoracic echocardiogram (TTE) findings including abnormalities of unclear significance or those at the upper or lower limit of the normal range and considered to potentially represent pathology (ie, left ventricular ejection fraction 50%). CMR indicates cardiac magnetic resonance imaging; cTn, cardiac troponin; and SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Figure 4.
Figure 4.
Cardiovascular testing results among NCAA athletes after SARS-CoV-2 infection. *Borderline triad testing as indication for CMR included detectable troponin level but not >99th percentile, nonspecific ECG abnormalities not fulfilling international criteria, and TTE findings including abnormalities of unclear significance or those at the upper or lower limit of the normal range and considered to potentially represent pathology (ie, left ventricular ejection fraction 50%). †New and known diagnoses. ASA indicates atrial septal aneurysm; ASD, atrial septal defect; CMR, cardiac magnetic resonance imaging; cTn, cardiac troponin; HCM, hypertrophic cardiomyopathy; LV, left ventricular; NCAA, National Collegiate Athletic Association; PFO, patent foramen ovale; RV, right ventricular; SARS-COV-2, severe acute respiratory syndrome coronavirus 2; and TTE, transthoracic echocardiogram.

Comment in

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