A new playbook: COVID-19, athletes’ hearts and return to play

BOSTON – Reports have indicated that COVID-19 may cause heart damage in hospitalized patients with severe cases of the disease, but it’s unclear whether cardiac injury also occurs in infected patients who are asymptomatic or experience only mild symptoms. This question is of particular concern for athletes because myocarditis—inflammation in the heart usually caused by a viral infection—can cause sudden cardiac death during exercise. In a special report published in JAMA Cardiology, a group led by sports cardiologists at Massachusetts General Hospital (MGH) and Emory University School of Medicine offers guidance for athletes’ return to play after they have recovered from COVID-19.

The article addresses the most common questions posed by the media, in clinics and athletic training rooms, and during discussions among cardiologists who care for athletes. With a consideration of evolving data, it represents a reassessment of a previous consensus statement by the American College of Cardiology that was published in May.

“This new set of recommendations is based on my and my fellow authors’ clinical experience treating athletes with COVID-19 over the past few months. Our primary objective was to outline an approach that reduced unnecessary testing while simultaneously ensuring we use resources responsibly to detect athletes at increased risk of adverse cardiac events attributable to the virus during their return to sports,” said senior author Aaron Baggish, MD, director of the Cardiovascular Performance Program at MGH.

Baggish and his colleagues have observed that athletes infected with COVID-19 who experienced no or mild symptoms did not exhibit signs of heart injury. For such athletes, they do not recommend detailed cardiac screening. The prevalence of cardiac injury in athletes who were infected with COVID-19 is still unknown, however, and the team believes it’s prudent to screen for heart damage in athletes with moderate to severe symptoms. The experts also note that despite recent small studies showing that cardiac magnetic resonance imaging has detected potential cardiac abnormalities in individuals who have recovered from COVID-19, they feel that current evidence doesn’t justify its use as a universal screening tool for athletes’ return to play.

“We hope the recommendations put forth in the document will assist practitioners in sports medicine, sports cardiology and general cardiology in the evaluation of athletes for return to play after COVID-19 infection,” said lead author Jonathan Kim, MD, MSc, chief of Cardiology Sports at Emory University School of Medicine. “These recommendations are intended to guide the process of determining who requires more detailed cardiac screening and ensure that all athletes post-COVID-19 infection should have a slow and gradual return to training with close monitoring of persistent symptoms, regardless of the severity of infection.”

The paper’s other authors were Benjamin D. Levine, MD, of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Dallas and The University of Texas Southwestern Medical Center; Dermot Phelan, MD, PhD, of the Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina; Michael S. Emery, MD, MS, of the Sports Cardiology Center, Department of Cardiovascular Medicine, Cleveland Clinic; Mathew W. Martinez, MD, of Morristown Medical Center, Atlantic Health System, Morristown, New Jersey; Eugene H. Chung, MD, MSc, of Michigan Medicine at the University of Michigan, Ann Arbor; and Paul D. Thompson, MD of Hartford Hospital in Connecticut.

About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In August 2020, Mass General was named #6 in the U.S. News & World Report list of "America’s Best Hospitals."