Updated testing guidance from a group of sports cardiologists for return to practice and competition after COVID-19 remained fairly conservative.
One of the notable changes was reducing the recommended period of “exercise abstinence” for competitive athletes without symptoms after a positive COVID-19 test — to 10 days from 14 previously — matching the shift in CDC guidelines for self-isolation.
Meanwhile, cardiac MRI (CMR) took a back seat in the testing recommended by the group led by Aaron Baggish, MD, of Massachusetts General Hospital in Boston and a team cardiologist for U.S. Olympic athletes, the New England Patriots, and other teams.
Their “narrative reassessment” of the May 2020 American College of Cardiology Sports and Exercise Cardiology Section recommendations, which some of the group had likewise authored, was reported in JAMA Cardiology.
Comprehensive cardiovascular testing should be considered, according to the recommendations, for groups including the following:
- Athletes with moderate or severe COVID-19
- Individuals with protracted COVID-19 symptoms of at least 10 days
- Those who develop symptoms during the escalation back into training
- Athletes older than 65, particularly those with pre-existing cardiovascular conditions or diabetes and those with persistent symptoms
Recommended first-line testing encompassed clinical evaluation, electrocardiogram (ECG), high sensitivity cardiac troponin (or available cardiac troponin), and echocardiography. If those findings are abnormal (or abnormal for an athlete) or if symptoms persist or recur or include cardiogenic syncope, then CMR could come into the picture, along with exercise testing and extended ambulatory rhythm monitoring.
CMR should also be prompted for people with persistently elevated troponin. Isolated ECG screening, though, “is of limited value because of the limited sensitivity for the detection of myocarditis (47%),” Baggish’s group wrote.
Clear cardiac involvement on testing even without well-defined myocarditis pathophysiology after COVID-19 infection should delay return to play in accord with myocarditis guidelines, they suggested.
There aren’t enough data to support CMR-based screening of all athletes with suspected or confirmed prior COVID-19 infection, as it hasn’t been shown to predict outcomes in the absence of symptoms suggestive of myocarditis, the group cautioned.
That was a more conservative take than the recent U.K. guidelines on return to play after COVID-19, noted James Udelson, MD, of Tufts Medical Center in Boston, and colleagues in an accompanying editorial.
Contrasting with the recommendation for no cardiovascular screening in most athletes who recover from COVID-19 with mild symptoms, the U.K. pathway recommends obtaining routine screening ECG, echocardiogram, and CMR as part of initial testing, they noted.
Baggish’s group “appropriately raise concern regarding the potential presence of isolated CMR abnormalities, which may lead to potentially inappropriate activity restrictions and downstream testing,” the editorialists noted.
And besides, there’s “no widely accepted definition of what constitutes clinically relevant myocardial injury secondary to COVID-19 infection among athletes in competitive sports,” Baggish and team added.
Which approach ultimately proves most prudent will only be clear with more time and data, Udelson and co-authors pointed out.
Gray-zone findings of unclear clinical relevance aren’t uncommon, emphasizing shared decision-making, Baggish and colleagues noted.
After the recommended isolation period for COVID-19, “a slow and carefully monitored resumption of activity, ideally under the direction of a certified athletic trainer” was suggested for any athlete with COVID-19, whether symptomatic or not.
Overall, the updated U.S. recommendations are likely to be “welcome news for front offices, administrators, and parents who are currently managing compromised budgets and would like to safely reduce diagnostic medical costs during this pandemic” and comforting for “athletes and sport coaches who seek an expedited normalization,” Udelson’s group wrote.
For clinicians caring for these patients, wearable device heart rate and stress load data will make monitoring the gradual return to training relatively routine in professional and collegiate settings, they predicted.
But youth sports typically don’t have the same medical and performance resources to monitor safe return to play. “This burden will fall on parents and coaches,” cautioned the editorialists. Trainers and coaches will need to “coordinate in a way that allows for ongoing and prudent risk assessment, emergency action planning, and subsequent contingency plans in the event cardiovascular stratification is warranted because of symptom development after infection and recovery.”
Recommendations for youth generally follow those of adults. Exceptions include the recommendation for formal evaluation by general pediatrics or pediatric cardiology for kids younger than 15 years recovering from moderate to severe COVID-19 infection, as well as close observation for multisystem inflammatory syndrome in high schoolers 15 and older who develop systemic or cardiovascular symptoms during or after infection.
Baggish reported research funding for the study of athletes in competitive sports from the National Heart, Lung, and Blood Institute, the National Football Players Association, and the American Heart Association, and compensation for his role as team cardiologist from the U.S. Olympic Committee/U.S. Olympic Training Centers, U.S. Soccer, U.S. Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University.
Udelson’s group reported no relevant conflicts of interest.