[Skip to Content]

Quiz

Coronavirus (COVID-19)

Coronavirus Disease 2019 and the Athletic HeartEmerging Perspectives on Pathology, Risks, and Return to Play

Educational Objective
To describe key diagnostic and management considerations for cardiovascular involvement in athletes with a history of coronavirus disease 2019 (COVID-19) infection.

1 Credit CME

JAMA Cardiology

Published Online: October 26, 2020

Special Communication

Article Information and Disclosures

Jonathan H. Kim, MD, MSc¹;

Benjamin D. Levine, MD^2,3;

Dermot Phelan, MD, PhD⁴;

Michael S. Emery, MD, MS⁵;

Mathew W. Martinez, MD⁶;

Eugene H. Chung, MD, MSc⁷;

Paul D. Thompson, MD⁸;

Aaron L. Baggish, MD⁹

Author Affiliations

¹Emory University School of Medicine, Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
²Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas
³The University of Texas Southwestern Medical Center, Dallas
⁴Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina
⁵Sports Cardiology Center, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
⁶Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
⁷Michigan Medicine, University of Michigan, Ann Arbor
⁸Hartford Hospital, Hartford, Connecticut
⁹Cardiovascular Performance Program, Massachusetts General Hospital, Boston

Read article on JAMA Network

Read Article Take Quiz

Abstract

Importance Cardiac injury with attendant negative prognostic implications is common among patients hospitalized with coronavirus disease 2019 (COVID-19) infection. Whether cardiac injury, including myocarditis, also occurs with asymptomatic or mild-severity COVID-19 infection is uncertain. There is an ongoing concern about COVID-19–associated cardiac pathology among athletes because myocarditis is an important cause of sudden cardiac death during exercise.

Observations Prior to relaxation of stay-at-home orders in the US, the American College of Cardiology’s Sports and Exercise Cardiology Section endorsed empirical consensus recommendations advising a conservative return-to-play approach, including cardiac risk stratification, for athletes in competitive sports who have recovered from COVID-19. Emerging observational data coupled with widely publicized reports of athletes in competitive sports with reported COVID-19–associated cardiac pathology suggest that myocardial injury may occur in cases of COVID-19 that are asymptomatic and of mild severity. In the absence of definitive data, there is ongoing uncertainty about the optimal approach to cardiovascular risk stratification of athletes in competitive sports following COVID-19 infection.

Conclusions and Relevance This report was designed to address the most common questions regarding COVID-19 and cardiac pathology in athletes in competitive sports, including the extension of return-to-play considerations to discrete populations of athletes not addressed in prior recommendations. Multicenter registry data documenting cardiovascular outcomes among athletes in competitive sports who have recovered from COVID-19 are currently being collected to determine the prevalence, severity, and clinical relevance of COVID-19–associated cardiac pathology and efficacy of targeted cardiovascular risk stratification. While we await these critical data, early experiences in the clinical oversight of athletes following COVID-19 infection provide an opportunity to address key areas of uncertainty relevant to cardiology and sports medicine practitioners.

Take Quiz

Sign in to take quiz and track your certificates

Buy This Activity

Article Information

Accepted for Publication: October 5, 2020.

Published Online: October 26, 2020. doi:10.1001/jamacardio.2020.5890

Corresponding Author: Aaron L. Baggish, MD, Cardiovascular Performance Program, Massachusetts General Hospital, 55 Fruit St, Yawkey Ste 5B, Boston, MA 02114 (abaggish@partners.org).

Author Contributions: Drs Baggish and Kim had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kim, Thompson.

Drafting of the manuscript: Kim, Phelan, Martinez.

Critical revision of the manuscript for important intellectual content: Kim, Levine, Emery, Martinez, Chung, Thompson, Baggish.

Administrative, technical, or material support: Kim, Emery.

Supervision: Kim, Levine, Emery, Chung, Baggish.

Conflict of Interest Disclosures: Dr Kim reported receiving research funding for the study of athletes in competitive sports from the National Institute of Health/National Heart, Lung, and Blood Institute, compensation for his role as team cardiologist from the Atlanta Falcons (in the National Football League), and research stipends from the Atlanta Track Club. Dr Levine reported receiving compensation for his role as a consultant cardiologist for USA Track and Field and the US Olympic Committee. Dr Thompson reported receiving research funding to his institution from Sanofi, Regeneron, Esperion, Amarin, and Amgen; receiving consultation fees or speaker honoraria from Amgen, Amarin, Kowa, Regeneron, Sanofi, Esperion, Kowa, and Boehringer Ingelheim; and owning stock in AbbVie, Abbott Labs, CVS, General Electric, J&J, Medtronic, Sarepta, Boston Scientific, Myokardia, and Moderna. Dr Martinez reported receiving compensation for his role as league cardiology consultant for Major League Soccer outside the submitted work. Dr Baggish reported receiving research funding for the study of athletes in competitive sports from the National Institute of Health/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 US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. No other disclosures were reported.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.