Inflamed Hearts in Athletes Reassuringly Rare After COVID

Cardiac involvement was rare among professional athletes whose positive COVID-19 tests prompted systematic cardiac screening, according to the largest such study to date.

Screening results turned out abnormal in 3.8% of 789 professional sports league players who underwent troponin testing, ECG, and resting echocardiography as part of a mandatory return-to-play cardiac testing program from May to October 2020.

Downstream cardiac MRI and/or stress echocardiography in these individuals showed myocarditis in three people and pericarditis in two, which was grounds for their temporary restriction from sports. Overall, this represented a 0.6% prevalence of inflammatory heart disease after SARS-CoV-2 infection, according to David Engel, MD, of Columbia University Irving Medical Center in New York City, and colleagues.

“It is important to note that none of the athletes in this cohort were clinically assessed as having severe COVID-19 viral illness. All of the five athletes that were identified as having inflammatory heart disease, however, had preceding symptoms that exceeded empirical definitions of mild COVID-19 illness (such as loss of taste and smell, nonspecific fatigue, and cough without dyspnea),” the group noted in JAMA Cardiology.

This is an important point that supports the judicious strategy of limiting cardiac screening to COVID-positive athletes with more moderate or severe symptoms, even when resources are not limited, commented Benjamin Levine, MD, of Texas Health Presbyterian Hospital Dallas and the University of Texas Southwestern Medical Center.

The strategy is in line with the American College of Cardiology’s recent expert consensus statement recommending that neither asymptomatic nor minimally symptomatic athletes need comprehensive cardiovascular screening unless their medical advisors decide otherwise.

“Such a practice also avoids the unfortunately too frequent outcome of screening healthy individuals, which is the identification of unrelated ‘abnormalities,’ which leads to the downstream consequence of additional testing and potential harm,” Levine told MedPage Today.

By December 2020, no adverse cardiac events occurred in athletes who were allowed to resume professional sport participation. The authors reported that long-term follow-up is ongoing.

In the meantime, it is “very reassuring” to see the low prevalence of inflammatory heart disease in the study, as myocarditis “raises the specter of increased risk for sudden cardiac death during sports,” according to Levine.

Study results counter previous cardiac MRI-based reports of higher rates of COVID-19 myocarditis and pericarditis in athletes.

Engel and colleagues stated that “our findings add support for the use of [cardiac MRI] as a clinically indicated and selective downstream test, rather than a tool to be applied in frontline and widespread screening, especially if clinical pretest probability is low.”

The study included players from Major League Soccer, Major League Baseball, the National Hockey League, the National Football League, and the men’s and women’s National Basketball Association. Cardiac testing was performed on average 19 days after a positive SARS-CoV-2 test result.

Participating athletes averaged age 25, and 98.5% were men. The cohort was divided between those who had symptomatic COVID-19 illness (58.3%) and those who were asymptomatic or minimally symptomatic (41.7%).

“Although the data presented are reassuring, it is important to acknowledge that we are still early in the process of understanding the cardiovascular consequences of COVID-19 infection in competitive athletes,” Levine cautioned. He said the study sample is still too small and the duration of follow-up too short “to be absolutely confident that there will not be a small but real number of serious clinical consequences of this disease.”

“Similar studies of other athletes, including pediatric, collegiate, and masters-level athletes, are required. Longitudinal assessment of athletes with prior COVID-19 infection remains necessary to enhance our understanding of the short-term and potential long-term pathologic cardiac sequelae of COVID-19 infection,” according to Engel’s group.