Prevalence of Inflammatory Heart Disease Among Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play Cardiac Screening | Cardiology | JN Learning | AMA Ed Hub [Skip to Content]
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Prevalence of Inflammatory Heart Disease Among Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play Cardiac Screening

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the prevalence of inflammatory heart disease identified through implementation of recent return-to-play (RTP) cardiac screening recommendations in professional athletes with prior coronavirus disease 2019 (COVID-19) infection?

Findings  In this cross-sectional study of RTP cardiac testing performed on 789 professional athletes with COVID-19 infection, imaging evidence of inflammatory heart disease that resulted in restriction from play was identified in 5 athletes (0.6%). No adverse cardiac events occurred in the athletes who underwent cardiac screening and resumed professional sport participation.

Meaning  Using expert consensus RTP screening recommendations for athletes testing positive for COVID-19, few cases of inflammatory heart disease were detected and safe return to professional sport activity has thus far been achieved.

Abstract

Importance  The major North American professional sports leagues were among the first to return to full-scale sport activity during the coronavirus disease 2019 (COVID-19) pandemic. Given the unknown incidence of adverse cardiac sequelae after COVID-19 infection in athletes, these leagues implemented a conservative return-to-play (RTP) cardiac testing program aligned with American College of Cardiology recommendations for all athletes testing positive for COVID-19.

Objective  To assess the prevalence of detectable inflammatory heart disease in professional athletes with prior COVID-19 infection, using current RTP screening recommendations.

Design, Setting, and Participants  This cross-sectional study reviewed RTP cardiac testing performed between May and October 2020 on professional athletes who had tested positive for COVID-19. The professional sports leagues (Major League Soccer, Major League Baseball, National Hockey League, National Football League, and the men’s and women’s National Basketball Association) implemented mandatory cardiac screening requirements for all players who had tested positive for COVID-19 prior to resumption of team-organized sports activities.

Exposures  Troponin testing, electrocardiography (ECG), and resting echocardiography were performed after a positive COVID-19 test result. Interleague, deidentified cardiac data were pooled for collective analysis. Those with abnormal screening test results were referred for additional testing, including cardiac magnetic resonance imaging and/or stress echocardiography.

Main Outcomes and Measures  The prevalence of abnormal RTP test results potentially representing COVID-19–associated cardiac injury, and results and outcomes of additional testing generated by the initial screening process.

Results  The study included 789 professional athletes (mean [SD] age, 25 [3] years; 777 men [98.5%]). A total of 460 athletes (58.3%) had prior symptomatic COVID-19 illness, and 329 (41.7%) were asymptomatic or paucisymptomatic (minimally symptomatic). Testing was performed a mean (SD) of 19 (17) days (range, 3-156 days) after a positive test result. Abnormal screening results were identified in 30 athletes (3.8%; troponin, 6 athletes [0.8%]; ECG, 10 athletes [1.3%]; echocardiography, 20 athletes [2.5%]), necessitating additional testing; 5 athletes (0.6%) ultimately had cardiac magnetic resonance imaging findings suggesting inflammatory heart disease (myocarditis, 3; pericarditis, 2) that resulted in restriction from play. No adverse cardiac events occurred in athletes who underwent cardiac screening and resumed professional sport participation.

Conclusions and Relevance  This study provides large-scale data assessing the prevalence of relevant COVID-19–associated cardiac pathology with implementation of current RTP screening recommendations. While long-term follow-up is ongoing, few cases of inflammatory heart disease have been detected, and a safe return to professional sports activity has thus far been achieved.

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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.

Article Information

Accepted for Publication: February 13, 2021.

Published Online: March 4, 2021. doi:10.1001/jamacardio.2021.0565

Corresponding Author: David J. Engel, MD, Division of Cardiology, Columbia University Irving Medical Center, ColumbiaDoctors Midtown, 51 W 51st St, Ste 330, New York, NY 10019 (de165@cumc.columbia.edu).

Author Contributions: Dr Engel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Martinez, Tucker, Bloom, DiFiori, Solomon, Phelan, Kim, Smith, Putukian, Engel.

Acquisition, analysis, or interpretation of data: Martinez, Tucker, Bloom, Green, DiFiori, Solomon, Kim, Meeuwisse, Sills, Rowe, Bogoch, Baggish, Putukian, Engel.

Drafting of the manuscript: Martinez, Bloom, Green, Phelan, Kim, Baggish, Engel.

Critical revision of the manuscript for important intellectual content: Tucker, Bloom, Green, DiFiori, Solomon, Phelan, Kim, Meeuwisse, Sills, Rowe, Bogoch, Smith, Baggish, Putukian, Engel.

Statistical analysis: Martinez, Rowe, Engel.

Administrative, technical, or material support: Martinez, Tucker, Green, Solomon, Rowe, Bogoch, Smith, Putukian, Engel.

Supervision: Martinez, Tucker, Green, DiFiori, Solomon, Phelan, Kim, Meeuwisse, Sills, Baggish, Putukian, Engel.

Conflict of Interest Disclosures: Dr Martinez reported personal fees from Major League Soccer as a consultant during the conduct of the study. Dr Green reported employment by Major League Baseball as a medical and research director. Dr DiFiori reported serving as a paid consultant for the National Basketball Association. Dr Solomon reported personal fees from National Football League during the conduct of the study and personal fees from the Nashville Predators and fees paid to a prior employer (Vanderbilt University Medical Center) from the Tennessee Titans outside the submitted work. Dr Kim reported compensation for his role as the team cardiologist for the Atlanta Falcons. Dr Meeuwisse reported serving as a chief medical officer employed by the National Hockey League. Dr Sills reported being a salaried employee of the National Football League during the conduct of the study. Dr Bogoch reported personal fees from BlueDot, a social benefit corporation that tracks the spread of emerging infectious diseases, and the National Hockey League Players’ Association during the conduct of the study. Dr Baggish reported receiving funding from the National Institute of Health/National Heart, Lung, and Blood Institute, the National Football League Players Association, and the American Heart Association and receives 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. Dr Putukian reported serving as a consultant and chief medical officer for Major League Soccer. No other disclosures were reported.

Additional Contributions: The authors thank the team physicians across all leagues, the professional athletes, and their respective players’ associations for their invaluable collaboration and cooperation. We would also like to thank all of the certified athletic trainers and other team medical staff members who provided care to the athletes and were instrumental in data collection.

References
1.
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
2.
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. 2020;5(11):1265-1273. doi:10.1001/jamacardio.2020.3557 PubMedGoogle ScholarCrossref
3.
Rajpal  S , Tong  MS , Borchers  J ,  et al.  Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection.   JAMA Cardiol. 2021;6(1):116-118. PubMedGoogle Scholar
4.
Starekova  J , Bluemke  DA , Bradham  WS ,  et al.  Evaluation for myocarditis in competitive student athletes recovering from coronavirus disease 2019 with cardiac magnetic resonance imaging.   JAMA Cardiol. Published online January 14, 2021. doi:10.1001/jamacardio.2020.7444 PubMedGoogle Scholar
5.
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. 2020;5(10):1085-1086. doi:10.1001/jamacardio.2020.2136 PubMedGoogle ScholarCrossref
6.
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
7.
Kim  JH , Levine  BD , Phelan  D ,  et al.  Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play.   JAMA Cardiol. 2021;6(2):219-227. doi:10.1001/jamacardio.2020.5890 PubMedGoogle ScholarCrossref
8.
Meyerowitz  EA , Richterman  A , Bogoch  II , Low  N , Cevik  M .  Towards an accurate and systematic characterisation of persistently asymptomatic infection with SARS-CoV-2.   Lancet Infect Dis. 2020;S1473-3099(20)30837-9. PubMedGoogle Scholar
9.
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
10.
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
11.
Brito  D , Meester  S , Yanamala  N ,  et al.  High prevalence of pericardial involvement in college student athletes recovering from COVID-19.   JACC Cardiovasc Imaging. 2020;S1936-878X(20)30946-3. doi:10.1016/j.jcmg.2020.10.023PubMedGoogle Scholar
12.
Kim  JH .  Screening athletes for myocarditis with cardiac magnetic resonance imaging after COVID-19 infection—lessons from an English philosopher.   JAMA Cardiol. 2021. doi:10.1001/jamacardio.2020.7463 PubMedGoogle Scholar
13.
Phelan  D , Kim  JH , Elliott  MD ,  et al.  Screening of potential cardiac involvement in competitive athletes recovering from COVID-19: an expert consensus statement.   JACC Cardiovasc Imaging. 2020;13(12):2635-2652. doi:10.1016/j.jcmg.2020.10.005 PubMedGoogle ScholarCrossref
14.
Engel  DJ , Schwartz  A , Homma  S .  Athletic cardiac remodeling in US professional basketball players.   JAMA Cardiol. 2016;1(1):80-87. doi:10.1001/jamacardio.2015.0252 PubMedGoogle ScholarCrossref
15.
Abergel  E , Chatellier  G , Hagege  AA ,  et al.  Serial left ventricular adaptations in world-class professional cyclists: implications for disease screening and follow-up.   J Am Coll Cardiol. 2004;44(1):144-149. doi:10.1016/j.jacc.2004.02.057 PubMedGoogle ScholarCrossref
16.
Teske  AJ , Prakken  NH , De Boeck  BW ,  et al.  Echocardiographic tissue deformation imaging of right ventricular systolic function in endurance athletes.   Eur Heart J. 2009;30(8):969-977. doi:10.1093/eurheartj/ehp040 PubMedGoogle ScholarCrossref
17.
Gandhi  RT , Lynch  JB , Del Rio  C .  Mild or moderate COVID-19.   N Engl J Med. 2020;383(18):1757-1766. doi:10.1056/NEJMcp2009249 PubMedGoogle ScholarCrossref
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