Resuming Training in High-Level Athletes After Mild COVID-19 Infection: A Multicenter Prospective Study (ASCCOVID-19)

Abstract

Background: There is a paucity of data on cardiovascular sequelae of asymptomatic/mildly symptomatic SARS-Cov-2 infections (COVID).

Objectives: The aim of this prospective study was to characterize the cardiovascular sequelae of asymptomatic/mildly symptomatic COVID-19 among high/elite-level athletes.

Methods: 950 athletes (779 professional French National Rugby League (F-NRL) players; 171 student athletes) were included. SARS-Cov-2 testing was performed at inclusion, and F-NRL athletes were intensely followed-up for incident COVID-19. Athletes underwent ECG and biomarker profiling (D-Dimer, troponin, C-reactive protein). COVID(+) athletes underwent additional exercise testing, echocardiography and cardiac magnetic resonance imaging (CMR).

Results: 285/950 athletes (30.0%) had mild/asymptomatic COVID-19 [79 (8.3%) at inclusion (COVID(+)_prevalent); 206 (28.3%) during follow-up (COVID(+)_incident)]. 2.6% COVID(+) athletes had abnormal ECGs, while 0.4% had an abnormal echocardiogram. During stress testing (following 7-day rest), COVID(+) athletes had a functional capacity of 12.8 ± 2.7 METS with only stress-induced premature ventricular ectopy in 10 (4.3%). Prevalence of CMR scar was comparable between COVID(+) athletes and controls [COVID(+) vs. COVID(-); 1/102 (1.0%) vs 1/28 (3.6%)]. During 289 ± 56 days follow-up, one athlete had ventricular tachycardia, with no obvious link with a SARS-CoV-2 infection. The proportion with troponin I and CRP values above the upper-limit threshold was comparable between pre- and post-infection (5.9% vs 5.9%, and 5.6% vs 8.7%, respectively). The proportion with D-Dimer values above the upper-limit threshold increased when comparing pre- and post-infection (7.9% vs 17.3%, P = 0.01).

Conclusion: The absence of cardiac sequelae in pauci/asymptomatic COVID(+) athletes is reassuring and argues against the need for systematic cardiac assessment prior to resumption of training (clinicaltrials.gov; NCT04936503).

Keywords: Cardiac MRI; ECG; Echocardiography; SARS-CoV-2; Sport; Stress test.

Fig. 1

Reported symptoms evocative of SARS-CoV-2 infection in the study population (regardless of SARS-COV-2 test results). Athletes presenting only clinical signs of SARS-COV-2 infection (anosmia or ageusia) with negative serology and PCR were excluded from the analysis as we could not establish the diagnosis with a sufficient level of certainty

Fig. 2

Occurrence of positive SARS-CoV-2 diagnosis during F-NRL season (RT-PCR and serologies). The F-NRL protocol involved twice-weekly SARS-CoV-2 RT-PCR testing (D614G variant). COVID(+) diagnosis was based on positive serology or a positive SARS-CoV-2 RT-PCR. 192/206 COVID(+)_incident cases were diagnosed by positive RT-PCR and 14 by positive serology (without previous positive RT-PCR). SARS-CoV-2 seroconversion (IgM and/or IgG) occurred in 155 (80.7%) of the 192 players diagnosed by RT-PCR, while 25 (13%) did not show detectable anti-SARS-CoV-2 antibodies during the follow-up period

Fig. 3

SARS-CoV-2 diagnosis and cardiovascular assessment results¹ among athletes included in the ASCCOVID study

Fig. 4

Late gadolinium enhancement CMR findings in athletes following mildly symptomatic COVID-19 infection. Yellow arrows indicate areas of LGE. A-B: small focal intramural LGE in the vicinity of the posterior RV insertion point. This pattern observed in equal proportions of COVID(+) and COVID(−) athletes, and considered as non-specific because suggestive of physiological remodeling. C: Intramural and sub-epicardial LGE lesion on infero-latero-basal LV segment, shown in short axis and 3-chamber views (top and bottom panel, respectively). The patient had experienced a mild symptomatic SARS-CoV-2 infection 65 days prior to the CMR study, with no clinical signs of myocarditis. Echocardiography, ECG and troponin tests were negative at inclusion. This CMR finding being suggestive of a post-inflammatory origin, scarring secondary to COVID-related myocarditis could not be ruled out