[Skip to Content]
Outline
Quiz
PDF
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
Jonathan H. Kim, MD, MSc1;
Benjamin D. Levine, MD2,3;
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

MOC/CME Information

editorial comment icon
Editorial
Comment
 related articles icon
Related
Articles
 author interview icon
Interviews
 multimedia icon
Multimedia
Audio Author Interview (20:30)
COVID-19 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return-to-Play
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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Related Articles

  1. Return to Play for Athletes After Coronavirus Disease 2019 Infection
    1.00 CME

  2. Researchers Investigate What COVID-19 Does to the Heart

Related Multimedia

  1. COVID-19 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return-to-Play
    0.25 CME

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

See More About

Cardiology Sports Medicine Coronavirus (COVID-19)
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.

References
1.
Phelan  D , Kim  JH , Chung  EH .  A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection.   JAMA Cardiol. Published May 13, 2020. doi:10.1001/jamacardio.2020.2136PubMedGoogle Scholar
2.
Clerkin  KJ , Fried  JA , Raikhelkar  J ,  et al.  COVID-19 and cardiovascular disease.   Circulation. 2020;141(20):1648-1655. doi:10.1161/CIRCULATIONAHA.120.046941 PubMedGoogle ScholarCrossref
3.
Baggish  A , Drezner  JA , Kim  J , Martinez  M , Prutkin  JM .  Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes.   Br J Sports Med. 2020;54(19):1130-1131. doi:10.1136/bjsports-2020-102516 PubMedGoogle ScholarCrossref
4.
Baggish  AL , Levine  BD .  Icarus and sports after COVID 19: too close to the sun?   Circulation. 2020;142(7):615-617. doi:10.1161/CIRCULATIONAHA.120.048335 PubMedGoogle ScholarCrossref
5.
Bhatia  RT , Marwaha  S , Malhotra  A ,  et al.  Exercise in the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) era: a question and answer session with the experts endorsed by the Section of Sports Cardiology & Exercise of the European Association of Preventive Cardiology (EAPC).   Eur J Prev Cardiol. 2020;27(12):1242-1251. doi:10.1177/2047487320930596 PubMedGoogle ScholarCrossref
6.
ESPN News Service. Boston Red Sox pitcher Eduardo Rodriguez done for season due to heart issue. Published August 1, 2020. Accessed October 13, 2020. https://www.espn.com/mlb/story/_/id/29579222/boston-red-sox-pitcher-eduardo-rodriguez-done-season-due-heart-issue
7.
Lavigne  P , Schlabach  M . Heart condition linked with COVID-19 fuels Power 5 concern about season's viability. Published August 10, 2020. Accessed October 5, 2020. https://www.espn.com/college-football/story/_/id/29633697/heart-condition-linked-covid-19-fuels-power-5-concern-season-viability
8.
Puntmann  VO , Carerj  ML , Wieters  I ,  et al.  Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19).   JAMA Cardiol. Published July 27, 2020. doi:10.1001/jamacardio.2020.3557 PubMedGoogle Scholar
9.
Rajpal  S , Tong  MS , Borchers  J ,  et al.  Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection.   JAMA Cardiol. Published September 11, 2020. doi:10.1001/jamacardio.2020.4916 PubMedGoogle Scholar
10.
Baggish  AL , Battle  RW , Beckerman  JG ,  et al; ACC’s Sports and Exercise Council Leadership Group.  Sports cardiology: core curriculum for providing cardiovascular care to competitive athletes and highly active people.   J Am Coll Cardiol. 2017;70(15):1902-1918. doi:10.1016/j.jacc.2017.08.055 PubMedGoogle ScholarCrossref
11.
Gandhi  RT , Lynch  JB , Del Rio  C .  Mild or moderate COVID-19.   N Engl J Med. 2020. doi:10.1056/NEJMcp2009249 PubMedGoogle Scholar
12.
Huang  C , Wang  Y , Li  X ,  et al.  Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.   Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5 PubMedGoogle ScholarCrossref
13.
Driggin  E , Madhavan  MV , Bikdeli  B ,  et al.  Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.   J Am Coll Cardiol. 2020;75(18):2352-2371. doi:10.1016/j.jacc.2020.03.031 PubMedGoogle ScholarCrossref
14.
Dolhnikoff  M , Ferreira Ferranti  J , de Almeida Monteiro  RA ,  et al.  SARS-CoV-2 in cardiac tissue of a child with COVID-19-related multisystem inflammatory syndrome.   Lancet Child Adolesc Health. 2020;4(10):790-794. doi:10.1016/S2352-4642(20)30257-1 PubMedGoogle ScholarCrossref
15.
Fox  SE , Li  G , Akmatbekov  A ,  et al.  Unexpected features of cardiac pathology in COVID-19 infection.   Circulation. 2020;142(11):1123-1125. doi:10.1161/CIRCULATIONAHA.120.049465 PubMedGoogle ScholarCrossref
16.
Lindner  D , Fitzek  A , Bräuninger  H ,  et al.  Association of cardiac infection with SARS-CoV-2 in confirmed COVID-19 autopsy cases.   JAMA Cardiol. 2020. doi:10.1001/jamacardio.2020.3551 PubMedGoogle Scholar
17.
Guo  T , Fan  Y , Chen  M ,  et al.  Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19).   JAMA Cardiol. 2020;5(7):811-818. doi:10.1001/jamacardio.2020.1017 PubMedGoogle ScholarCrossref
18.
Baggish  AL , Battle  RW , Beaver  TA ,  et al.  Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: a report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance.   J Am Soc Echocardiogr. 2020;33(5):523-549. doi:10.1016/j.echo.2020.02.009 PubMedGoogle ScholarCrossref
19.
Shave  R , Baggish  A , George  K ,  et al.  Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications.   J Am Coll Cardiol. 2010;56(3):169-176. doi:10.1016/j.jacc.2010.03.037 PubMedGoogle ScholarCrossref
20.
La Gerche  A , Burns  AT , Mooney  DJ ,  et al.  Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes.   Eur Heart J. 2012;33(8):998-1006. doi:10.1093/eurheartj/ehr397 PubMedGoogle ScholarCrossref
21.
Churchill  TW , Groezinger  E , Loomer  G ,  et al.  Training-associated changes in ventricular volumes and function in elite female runners.   Circ Cardiovasc Imaging. 2020;13(6):e010567. doi:10.1161/CIRCIMAGING.120.010567 PubMedGoogle Scholar
22.
Kim  JH , Baggish  AL .  Differentiating exercise-induced cardiac adaptations from cardiac pathology: the “grey zone” of clinical uncertainty.   Can J Cardiol. 2016;32(4):429-437. doi:10.1016/j.cjca.2015.11.025 PubMedGoogle ScholarCrossref
23.
Sandoval  Y , Januzzi  JL  Jr , Jaffe  AS .  Cardiac troponin for assessment of myocardial injury in COVID-19: JACC review topic of the week.   J Am Coll Cardiol. 2020;76(10):1244-1258. doi:10.1016/j.jacc.2020.06.068 PubMedGoogle ScholarCrossref
24.
Shi  S , Qin  M , Shen  B ,  et al.  Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China.   JAMA Cardiol. 2020;5(7):802-810. doi:10.1001/jamacardio.2020.0950PubMedGoogle ScholarCrossref
25.
Omland  T , de Lemos  JA , Holmen  OL ,  et al.  Impact of sex on the prognostic value of high-sensitivity cardiac troponin I in the general population: the HUNT study.   Clin Chem. 2015;61(4):646-656. doi:10.1373/clinchem.2014.234369 PubMedGoogle ScholarCrossref
26.
Collinson  P , Hammerer-Lercher  A , Suvisaari  J ,  et al; Working Group for Cardiac Markers, European Federation of Clinical Chemistry and Laboratory Medicine.  How well do laboratories adhere to recommended clinical guidelines for the management of myocardial infarction: the Cardiac Marker Guidelines Uptake in Europe Study (CARMAGUE).   Clin Chem. 2016;62(9):1264-1271. doi:10.1373/clinchem.2016.259515 PubMedGoogle ScholarCrossref
27.
Ferreira  VM , Schulz-Menger  J , Holmvang  G ,  et al.  Cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations.   J Am Coll Cardiol. 2018;72(24):3158-3176. doi:10.1016/j.jacc.2018.09.072 PubMedGoogle ScholarCrossref
28.
Maron  BJ , Udelson  JE , Bonow  RO ,  et al; American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, Council on Cardiovascular Disease in Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and American College of Cardiology.  Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 3, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology.   Circulation. 2015;132(22):e273-e280.PubMedGoogle Scholar
29.
Churchill  TW , Disanto  M , Singh  TK ,  et al.  Diagnostic yield of customized exercise provocation following routine testing.   Am J Cardiol. 2019;123(12):2044-2050. doi:10.1016/j.amjcard.2019.03.027 PubMedGoogle ScholarCrossref
30.
Fung  G , Luo  H , Qiu  Y , Yang  D , McManus  B .  Myocarditis.   Circ Res. 2016;118(3):496-514. doi:10.1161/CIRCRESAHA.115.306573 PubMedGoogle ScholarCrossref
31.
Kiel  RJ , Smith  FE , Chason  J , Khatib  R , Reyes  MP .  Coxsackievirus B3 myocarditis in C3H/HeJ mice: description of an inbred model and the effect of exercise on virulence.   Eur J Epidemiol. 1989;5(3):348-350. doi:10.1007/BF00144836 PubMedGoogle ScholarCrossref
32.
Maron  BJ , Doerer  JJ , Haas  TS , Tierney  DM , Mueller  FO .  Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006.   Circulation. 2009;119(8):1085-1092. doi:10.1161/CIRCULATIONAHA.108.804617 PubMedGoogle ScholarCrossref
33.
Phillips  M , Robinowitz  M , Higgins  JR , Boran  KJ , Reed  T , Virmani  R .  Sudden cardiac death in Air Force recruits: a 20-year review.   JAMA. 1986;256(19):2696-2699. doi:10.1001/jama.1986.03380190066026 PubMedGoogle ScholarCrossref
34.
Caforio  AL , Pankuweit  S , Arbustini  E ,  et al; European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.  Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.   Eur Heart J. 2013;34(33):2636-2648, 2648a-2648d. doi:10.1093/eurheartj/eht210PubMedGoogle ScholarCrossref
35.
Pelliccia  A , Solberg  EE , Papadakis  M ,  et al.  Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC).   Eur Heart J. 2019;40(1):19-33. doi:10.1093/eurheartj/ehy730 PubMedGoogle ScholarCrossref
36.
Sharma  S , Drezner  JA , Baggish  A ,  et al.  International recommendations for electrocardiographic interpretation in athletes.   J Am Coll Cardiol. 2017;69(8):1057-1075. doi:10.1016/j.jacc.2017.01.015 PubMedGoogle ScholarCrossref
37.
Vyas  DA , Eisenstein  LG , Jones  DS .  Hidden in plain sight—reconsidering the use of race correction in clinical algorithms.   N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740 PubMedGoogle ScholarCrossref
38.
US Centers for Disease Control and Prevention. Duration of isolation and precautions for adults with COVID-19. Updated September 10, 2020. Accessed October 14, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
39.
Yonker  LM , Neilan  AM , Bartsch  Y ,  et al.  Pediatric SARS-CoV-2: clinical presentation, infectivity, and immune responses.   J Pediatr. 2020;S0022-3476(20)31023-4. PubMedGoogle Scholar
40.
Feldstein  LR , Rose  EB , Horwitz  SM ,  et al; Overcoming COVID-19 Investigators; CDC COVID-19 Response Team.  Multisystem inflammatory syndrome in U.S. children and adolescents.   N Engl J Med. 2020;383(4):334-346. doi:10.1056/NEJMoa2021680 PubMedGoogle ScholarCrossref
41.
Canter  CE , Simpson  KE .  Diagnosis and treatment of myocarditis in children in the current era.   Circulation. 2014;129(1):115-128. doi:10.1161/CIRCULATIONAHA.113.001372 PubMedGoogle ScholarCrossref
42.
Parizher  G , Putzke  JD , Lampert  R ,  et al.  Web-based multimedia athlete preparticipation questionnaire: introducing the video-PPE (v-PPE).   Br J Sports Med. 2020;54(1):67-68. doi:10.1136/bjsports-2018-100524 PubMedGoogle ScholarCrossref
43.
Morgera  T , Di Lenarda  A , Dreas  L ,  et al.  Electrocardiography of myocarditis revisited: clinical and prognostic significance of electrocardiographic changes.   Am Heart J. 1992;124(2):455-467. doi:10.1016/0002-8703(92)90613-Z PubMedGoogle ScholarCrossref
44.
Svedberg  N , Sundström  J , James  S , Hållmarker  U , Hambraeus  K , Andersen  K .  Long-term incidence of atrial fibrillation and stroke among cross-country skiers.   Circulation. 2019;140(11):910-920.PubMedGoogle Scholar
45.
DeFina  LF , Radford  NB , Barlow  CE ,  et al.  Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification.   JAMA Cardiol. 2019;4(2):174-181. doi:10.1001/jamacardio.2018.4628 PubMedGoogle ScholarCrossref
46.
Sharma  S , Zaidi  A .  Exercise-induced arrhythmogenic right ventricular cardiomyopathy: fact or fallacy?   Eur Heart J. 2012;33(8):938-940. doi:10.1093/eurheartj/ehr436 PubMedGoogle ScholarCrossref
47.
Abdullah  SM , Barkley  KW , Bhella  PS ,  et al.  Lifelong physical activity regardless of dose is not associated with myocardial fibrosis.   Circ Cardiovasc Imaging. 2016;9(11):e005511. doi:10.1161/CIRCIMAGING.116.005511 PubMedGoogle Scholar
48.
Baggish  AL , Ackerman  MJ , Lampert  R .  Competitive sport participation among athletes with heart disease: a call for a paradigm shift in decision making.   Circulation. 2017;136(17):1569-1571. doi:10.1161/CIRCULATIONAHA.117.029639 PubMedGoogle ScholarCrossref
49.
Levine  BD , Stray-Gundersen  J .  The medical care of competitive athletes: the role of the physician and individual assumption of risk.   Med Sci Sports Exerc. 1994;26(10):1190-1192. doi:10.1249/00005768-199410000-00002 PubMedGoogle ScholarCrossref
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 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

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

Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue