Return-to-play screening finds inflammatory heart disease in less than 1% of players post-infection

A cross-sectional analysis of professional athletes with prior Covid-19 infection found that less than 1% of athletes showed signs of inflammatory heart disease preventing them from returning to the field, researchers found.

Major North American professional sports leagues — including Major League Soccer (MLS), Major League Baseball (MLB), the National Hockey League (NHL), the National Football League (NFL), and the men’s and women’s National Basketball Associations (NBA and WNBA, respectively) — were among the first sports organizations to start playing again during the Covid-19 pandemic. Since cardiac injury has been observed at increased rates among patients hospitalized with SARS-CoV-2 infection, each of these leagues implemented programs for pre-participation return-to-play (RTP) cardiac testing for any athletes who tested positive for Covid-19.

And, according to David J. Engel, MD, of the Division of Cardiology at Columbia University Irving Medical Center in New York City, and colleagues, the rates of Covid-related heart injury have been low.

“Through RTP cardiac screening for professional athletes testing positive for Covid-19, 0.6% (5 of 789 athletes) had imaging findings suggestive of inflammatory heart disease that resulted in restriction from play in alignment with American Heart Association/ACC guidelines,” Engel and colleagues wrote in JAMA Cardiology. “With implementation of current expert consensus–based cardiovascular risk stratification practices, safe return to professional sporting activity has thus far been achieved, with no cardiovascular events occurring within these professional leagues during and on completion of competitive play in 2020.”

However, they added that it is “important to note that none of the athletes in this cohort were clinically assessed as having severe Covid-19 viral illness,” but all five athletes who were identified as having inflammatory heart disease post-infection “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).” Based on this finding, Engel and colleagues suggested that ascertained symptom burden should be “a primary reference point to guide the next steps in the evaluation of the athlete testing positive for Covid-19.”

For their analysis, the study authors reviewed RTP cardiac testing performed between May and October 2020 on professional athletes who tested positive for Covid-19. The study included 789 athletes (mean [SD] age, 25 [3] years; 777 men [98.5%]), of whom 460 (58.3%) had prior symptomatic Covid-19 and 329 (41.7%) had asymptomatic or paucisymptomatic infection.

Troponin testing, electrocardiography (ECG), and resting echocardiography were performed a mean (SD) of 19 (17) days (range, 3-156 days) after a positive test result, and interleague, deidentified cardiac data were pooled for collective analysis. Athletes with abnormal screening results were referred for additional testing, including cardiac magnetic resonance (CMR) imaging and/or stress echocardiography. The primary study outcomes included 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.

“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,” they found. “No adverse cardiac events occurred in athletes who underwent cardiac screening and resumed professional sport participation.”

Engel and colleagues noted that their finding of low prevalence of clinically detectable inflammatory heart disease among professional athletes “offers a counterpoint to findings of higher rates of Covid-19 myocarditis and pericarditis reported in recent small cohort and CMR-based observational studies in athletes.” They argued that the difference between detected and reported abnormalities between this and past trials highlight difficulties in using CMR as a stand-alone screening tool in Covid-19 RTP risk stratification, suggesting that CMR should be used 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 authors also noted that five athletes included in their analysis had isolated abnormal troponin test results without other clinical or imaging evidence of cardiac injury, arguing that these false-positive results underscore the fact that “established 99th percentile reference ranges for troponin levels do not include elite athletes,” supporting recommendations that “biomarker interpretation must be incorporated with additional cardiac test results and assessed in context with supporting clinical factors.”

And, they added, low specificity among EEG results and the rates of unnecessary additional cardiac testing prompted by echocardiographic findings in this analysis suggest that “significant challenges remain with using echocardiography in elite athletes to distinguish athletic remodeling from potential Covid-19–associated cardiac pathology. The ability to compare echocardiographic findings with prior, pre–Covid-19 examinations, if available, is valuable when interpreting RTP screening echocardiograms. The limitations observed with echocardiography presented in this study, along with the need to balance resource management across health care systems, will be essential elements to incorporate in the refinement of RTP screening practices.”

Study limitations included a decentralized testing structure that prevents the study authors from providing uniform criteria for diagnosing Covid-19-associated inflammatory heart disease; the variability in time between Covid-19 testing and cardiac screening; and that over 98% of study participants were male.

  1. Return-to-play cardiac screening of professional athletes who had tested positive for Covid-19 found that less than 1% of infected players suffered from subsequent Covid-19-associated inflammatory heart disease.
  2. The study authors suggest that ascertained symptom burden should be a primary reference point to guide the next steps in the evaluation of the athletes who test positive for Covid-19.

John McKenna, Associate Editor, BreakingMED™

Study coauthor Martinez reported personal fees from MLS during the conduct of the study; coauthor Green reported employment by MLB as a medical and research director; coauthor DiFiori reported serving as a paid consultant for the NBA; coauthor Solomon reported personal fees from the NFL during the conduct of the study; coauthor Kim reported compensation for his role as team cardiologist for the Atlanta Falcons; coauthor Meeuwisse reported serving as chief medical officer for the NHL; coauthor Baggish reported funding from NIH, the National Heart, Lung, and Blood Institute, the NFL Players Association, and the American Heart Association and compensation for his role as team cardiologist for the U.S. Olympic Committee/U.S. Olympic Training Centers, U.S. Soccer, U.S. Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University; coauthor Putukian reported serving as a consultant and chief medical officer for MLS.


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