A prospective study on the consequences of SARS-CoV-2 infection on the heart of young adult competitive athletes: Implications for a safe return-to-play

Abstract

Objectives: The COVID-19 pandemic has shocked the sports world because of the suspension of competitions and the spread of SARS-CoV-2 among athletes. After SARS-CoV-2 infection, cardio-pulmonary complications can occur and, before the resumption of sports competitions, a screening has been recommended. However, few data are available and discrepancies exist in the screening modalities. We conducted this prospective study to investigate the incidence of cardiovascular consequences following SARS-CoV-2 infection in young adult competitive athletes and the appropriate screening strategies for a safe return-to-play.

Methods: Ninety competitive athletes (24 ± 10 years) after asymptomatic or mildly symptomatic SARS-CoV-2 infection were screened by physical examination, blood testing, spirometry, 12‑lead resting ECG, 24-h ambulatory ECG monitoring, echocardiogram, and cardiopulmonary exercise testing (CPET).

Results: Sixty-four athletes (71.1%) were male, and most (76.7%) were mildly symptomatic. After SARS-CoV-2 infection, spirometry and resting ECG were normal in all athletes. Ambulatory ECG monitoring demonstrated <50/24 h supraventricular and ventricular premature beats in 53.3% and 52.2% of athletes, respectively, in the absence of malignant arrhythmias. CPET did not demonstrate cardiopulmonary limitations. Echocardiography showed pericardial effusion in 3 athletes (all females) with symptomatic SARS-CoV-2 infection (3.3%; 4.4% in the symptomatic group) with a definitive diagnosis of myopericarditis in 1 athlete (1.1%) and pericarditis in 2 athletes (2.2%).

Conclusions: Cardiac consequences of SARS-CoV-2 infection were found in 3.3% of competitive athletes. An appropriate screening primarily based on the detection of uncommon arrhythmias and cardiac symptoms should be recommended in competitive athletes after SARS-CoV-2 infection to detect a cardiac involvement and guarantee a safe return-to-play.

Keywords: Athletes; COVID-19; Myocarditis, pericarditis; Pre-participation screening; Return-to-play; SARS-CoV-2 infection.

Fig. 1

Central illustration summarizing the main findings of the study.

Fig. 2

Proposal of a clinical algorithm to screen competitive athletes recovering from SARS-CoV-2 infection before their return-to-play. *The test is indicated on a case-by-case decision, based on clinical symptoms, individual risk profile and clinical course of Covid-19 infection. ^New pre-participation evaluation should be performed according to national modalities and recommendations. § in case of abnormal 12‑lead resting ECG, uncommon ventricular arrhythmias or cardiac symptoms.

Supplementary Fig. 1

Clinical findings in a competitive athlete with myopericarditis after SARS-CoV-2 infection. Exercise-induced uncommon ventricular arrhythmias and mild pericardial effusion were demonstrated during the screening; accordingly, a cardiac magnetic resonance was performed, confirming pericardial effusion and demonstrating the presence of late gadolinium enhancement.