Clinical spectrum of COVID-19 complications in young adults: combined analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry and the Outcomes Registry for Cardiac Conditions in Athletes.

BACKGROUND: While young adults 18-24 years old bear a significant proportion of COVID-19 diagnoses, the risk factors for hospitalisation and severe COVID-19 complications in this population are poorly understood. OBJECTIVE: The objective of this study was to identify risk factors for hospitalisation and other COVID-19 complications across the health spectrum of young adults diagnosed with COVID-19 infection. STUDY DESIGN: Retrospective cohort study. PARTICIPANTS: Young adults (aged 18-24) with confirmed COVID-19 infection from the American Heart Association (AHA) COVID-19 Cardiovascular Disease Registry of hospitalised patients and the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study of collegiate athletes. The AHA registry included 636 young adults from 152 hospitals. The ORCCA registry consisted of 3653 competitive college athletes from 42 colleges and universities. INTERVENTION: None (exposure to COVID-19). PRIMARY AND SECONDARY OUTCOME MEASURES: Main outcomes included hospitalisation, death, major adverse cardiovascular events (MACE) and other severe clinical events. RESULTS: In comparison to the ORCCA registry, patients in the AHA registry were more likely to be female (59% vs 33%); had higher average body mass index (BMI) (32.4 vs 25.6); and had increased prevalence of diabetes (10% vs 0.4%), hypertension (7% vs 0.6%), chronic kidney disease (2% vs 0%) and asthma (14% vs 8%), all with p<0.01. There were eight (2%) deaths in the AHA hospitalised registry compared with zero in the ORCCA cohort. BMI was a statistically significant predictor of death in the hospitalised cohort (OR 1.05, 95% CI 1.00, 1.10). No significant predictors of MACE or other severe clinical events were identified. CONCLUSIONS: The risk of cardiac events in young adults aged 18-24 diagnosed with COVID-19 infection is low. Patients who were hospitalised (AHA registry) were more likely to have pre-existing medical comorbidities and higher BMI than healthy collegiate athletes (ORCCA registry). Once hospitalised, elevated BMI is associated with increased mortality although other drivers of MACE and other severe clinical events remain unclear.

The Cardiac Effects of COVID-19 on Young Competitive Athletes: Results from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA).

The Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study is a large-scale prospective investigation evaluating the cardiovascular effects and outcomes of SARS-CoV-2 infection on young competitive athletes. This review provides an overview of the key results from the ORCCA study. Results from the ORCCA study have provided important insights into the clinical impact of SARS-CoV-2 infection on the cardiovascular health of young competitive athletes and informed contemporary screening and return to sport practices. Key results include defining a low prevalence of both cardiac involvement and adverse cardiovascular outcomes after SARS-CoV-2 infection and evaluating the utility of a return-to-play cardiac evaluation. Future aims of the ORCCA study include the longer-term evaluation of cardiovascular outcomes among athletes post-SARS-CoV-2 infection and the transition to investigating outcomes in young athletes with potentially high-risk genetic or structural cardiac diagnoses.

Cardiac Troponin Testing as a Component of Return to Play Cardiac Screening in Young Competitive Athletes Following SARS-CoV-2 Infection.

Background Initial protocols for return to play cardiac testing in young competitive athletes following SARS-CoV-2 infection recommended cardiac troponin (cTn) to screen for cardiac involvement. This study aimed to define the diagnostic yield of cTn in athletes undergoing cardiovascular testing following SARS-CoV-2 infection. Methods and Results This prospective, observational cohort study from ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) included collegiate athletes who underwent cTn testing as a component of return to play protocols following SARS-CoV-2 infection. The cTn values were stratified as undetectable, detectable but within normal limits, and abnormal (>99% percentile). The presence of probable or definite SARS-CoV-2 myocardial involvement was compared between those with normal versus abnormal cTn levels. A total of 3184/3685 (86%) athletes in the ORCCA database met the inclusion criteria for this study (age 20±1 years, 32% female athletes, 28% Black race). The median time from SARS-CoV-2 diagnosis to cTn testing was 13 days (interquartile range, 11, 18 days). The cTn levels were undetectable in 2942 athletes (92%), detectable but within normal limits in 210 athletes (7%), and abnormal in 32 athletes (1%). Of the 32 athletes with abnormal cTn testing, 19/32 (59%) underwent cardiac magnetic resonance imaging, 30/32 (94%) underwent transthoracic echocardiography, and 1/32 (3%) did not have cardiac imaging. One athlete with abnormal troponin met the criteria for definite or probable SARS-CoV-2 myocardial involvement. In the total cohort, 21/3184 (0.7%) had SARS-CoV-2 myocardial involvement, among whom 20/21 (95%) had normal troponin testing. Conclusions Abnormal cTn during routine return to play cardiac screening among competitive athletes following SARS-CoV-2 infection appears to have limited diagnostic utility.

Electrocardiographic findings in young competitive athletes during acute SARS-CoV-2 infection.

Initial guidelines recommended a 12-lead electrocardiogram (ECG) in young competitive athletes following SARS-CoV-2 infection to screen for myocarditis. However, no data are available that detail ECG findings before and after SARS-CoV-2 infection in young athletes without clinical or imaging evidence of overt myocarditis. This study applied the International Criteria for ECG interpretation in a cohort of 378 collegiate athletes to compare ECG findings at baseline and during the acute phase of SARS-CoV-2 infection. Our results suggest that ECG changes can occur in the absence of definitive SARS-CoV-2 cardiac involvement in young competitive athletes.

The Impact of COVID-19 Related School Closures and SPORT CANCELLATIONS on the Health of Adolescent Athletes

Background: In March 2020, schools were closed to in-person teaching and interscholastic sports cancelled in an attempt to slow the spread of the COVID-19. Child health experts have stated that school closures may have profound psychosocial consequences for students and need further study. Hypothesis/Purpose: To identify how COVID-19 related school closures and sport cancellations impacted the health of adolescent athletes. Methods: Adolescent athletes in Wisconsin were recruited via social media to complete an online survey in May 2020 while schools were closed to in-person teaching and interscholastic and club sports were cancelled. Assessments included the: General Anxiety Disorder-7 Item (GAD-7) for anxiety, Patient Health Questionnaire-9 Item (PHQ-9) for depression, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for quality of life. PHQ-9, PFABS and PedsQL scores were compared with historical data (HD) of Wisconsin adolescent athletes (N = 5,231) collected during normal school and sport operations in the years 2016–2018. Results: A total of 3,243 (58% female, Age = 16.1+1.2 yrs., grades 9 – 12) participated in the study. May 2020 participants reported higher (worse) PHQ-9 scores than the HD participants (mean: 8.0 (95%CI: 7.8, 8.2) vs 3.3 (3.1, 3.5), p < 0.001) as well as a higher prevalence of moderate to severe levels of depression (32.9% vs 9.7%, p < 0.001). May 2020 Participants also reported lower (worse) PFABS scores (mean: 12.2 (95%CI: 11.9, 12.5) vs 24.7 (24.5, 24.9) p < 0.001) and lower (worse) PedsQL total scores compared to athletes in the HD group (78.4 (78.0, 78.8) vs. 90.9 (90.5, 91.3) p < 0.001). Females in May 2020 reported increased moderate and severe anxiety percentages than the males in May 2020 (27.7% vs 22.3%, p < 0.001). Conclusions: COVID-19 related school closures and sport cancellations in Wisconsin were associated with increased anxiety and depression as well as decreased physical activity and quality of life in adolescent athletes. The potential negative health impacts of prolonged school closures and sport cancellations should be taken into account when evaluating steps to limit the spread of COVID-19.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents.

CONTEXT: During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown. OBJECTIVE: To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes. DESIGN: Cross-sectional study. SETTING: Sample recruited via email. PATIENTS OR OTHER PARTICIPANTS: A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP). MAIN OUTCOME MEASURE(S): Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch. RESULTS: The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001). CONCLUSIONS: Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

Increased Incidence of Injury Among Runners With COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) affects multiple organ systems. Whether and how COVID-19 affects the musculoskeletal system remains unknown. We aim to assess the association between COVID-19 and risk of injury. HYPOTHESIS: Runners who report having COVID-19 also report a higher incidence of injury. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: An electronic survey was distributed from July through September 2020, by New York Road Runners, ASICS North America, race medical directors, and through social media. Inclusion criteria were runners 18 years or older who had participated in ≥1 race (running or triathlon) in 2019. RESULTS: A total of 1947 runners participated and met inclusion criteria. Average age was 45.0 (SD, 12.2) years and 56.5% were women. A total of 123 (6.3%) runners self-reported having COVID-19; 100 (81%) reported their diagnosis was from a laboratory test (polymerase chain reaction or antibody) and 23 reported being diagnosed by a medical professional without confirmatory laboratory testing. Since March 2020, 427 (21.9%) reported an injury that prevented running for at least 1 week, including 38 of 123 (30.9%) who self-reported having COVID-19 and 389 of 1435 (21.3%) who did not report having COVID-19 (P = 0.01). After adjusting for age, sex, the number of races in 2019, and running patterns before March 2020, runners who self-reported a diagnosis of COVID-19 had a higher incidence of injury compared with those who did not (odds ratio, 1.66; 95% CI, 1.11-2.48; P = 0.01). CONCLUSION: Injuries were more often self-reported by runners with laboratory-confirmed or clinically diagnosed COVID-19 compared with those who did not report COVID-19. Given the limitations of the study, any direct role of COVID-19 in the pathophysiology of injuries among runners remains unclear. CLINICAL RELEVANCE: Direct and indirect musculoskeletal sequelae of COVID-19 should be further investigated, including the risk of exercise- and sports-related injury after COVID-19.

Running races during the COVID-19 pandemic: a 2020 survey of the running community.

OBJECTIVES: To survey runners and triathletes about their willingness to resume in-person racing during the COVID-19 pandemic, health concerns related to mass races and changes in running patterns since the start of the pandemic. DESIGN: An electronic survey was distributed from 15 July to 1 September 2020 to runners and triathletes by New York Road Runners, ASICS North America, and race medical directors, and through social media. PARTICIPANTS: Runners and triathletes 18 years of age or older who participated in at least one race in 2019. RESULTS: A total of 2278 surveys were received. Not all participants answered every question; the denominator represents the number of responses to each question. Most participants were from the USA (1620/1940, 83.5%), of which over half were from New York (812/1475, 55.1%). Regarding when respondents would feel comfortable returning to in-person racing, the most frequent response was 'Whenever local laws allow, but only if there are sufficient precautions' (954/2173, 43.9%), followed by 'Not until there is a vaccine' (540/2173, 24.9%). The most common concerns about in-person races were crowded starting corrals (1802/2084, 86.5%), the number of COVID-19 cases in the race location (1585/2084, 76.1%) and the number of participants (1517/2084, 72.8%). Comparing running patterns before the pandemic to Summer 2020, the mean weekly mileage decreased from 25.5 (SD 15.4) miles to 22.7 (16.2) miles (p<0.001). CONCLUSION: Most runners are willing to return to racing when local laws allow, though as of Summer 2020, many desired certain precautions to feel comfortable.

Prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms following SARS-CoV-2 infection in 3597 collegiate athletes: a study from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA).

OBJECTIVE: To assess the prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms in young competitive athletes following SARS-CoV-2 infection. METHODS: This observational cohort study from the Outcomes Registry for Cardiac Conditions in Athletes included 3597 US collegiate athletes after SARS-CoV-2 infection. Clinical characteristics, advanced diagnostic testing and SARS-CoV-2-associated sequelae were compared between athletes with persistent symptoms >3 weeks, exertional symptoms on return to exercise and those without persistent or exertional symptoms. RESULTS: Among 3597 athletes (mean age 20 years (SD, 1 year), 34% female), data on persistent and exertional symptoms were reported in 3529 and 3393 athletes, respectively. Persistent symptoms >3 weeks were present in 44/3529 (1.2%) athletes with 2/3529 (0.06%) reporting symptoms >12 weeks. Exertional cardiopulmonary symptoms were present in 137/3393 (4.0%) athletes. Clinical evaluation and diagnostic testing led to the diagnosis of SARS-CoV-2-associated sequelae in 12/137 (8.8%) athletes with exertional symptoms (five cardiac involvement, two pneumonia, two inappropriate sinus tachycardia, two postural orthostatic tachycardia syndrome and one pleural effusion). No SARS-CoV-2-associated sequelae were identified in athletes with isolated persistent symptoms. Of athletes with chest pain on return to exercise who underwent cardiac MRI (CMR), 5/24 (20.8%) had probable or definite cardiac involvement. In contrast, no athlete with exertional symptoms without chest pain who underwent CMR (0/20) was diagnosed with probable or definite SARS-CoV-2 cardiac involvement. CONCLUSION: Collegiate athletes with SARS-CoV-2 infection have a low prevalence of persistent or exertional symptoms on return to exercise. Exertional cardiopulmonary symptoms, specifically chest pain, warrant a comprehensive evaluation.

Surveillance testing for SARS-COV-2 infection in an asymptomatic athlete population: a prospective cohort study with 123 362 tests and 23 463 paired RT-PCR/antigen samples.

OBJECTIVE: To assess the diagnostic accuracy of antigen compared with reverse transcriptase (RT)-PCR testing in an asymptomatic athlete screening programme and to monitor infection in college athletes. METHODS: Quidel Sofia-2 SARS-CoV-2 Antigen Tests were performed daily before sports participation for football, basketball, wrestling and water polo from 29 September 2020 to 28 February 2021. Paired RT-PCR and antigen tests were performed at least once a week. Positive antigen tests were confirmed with RT-PCR. RESULTS: 81 175 antigen and 42 187 RT-PCR tests were performed, including 23 462 weekly paired antigen/RT-PCR screening tests in 1931 athletes. One hundred and seventy-two athletes had a positive screening RT-PCR (0.4%), of which 83 (48%) occurred on paired testing days. The sensitivity of antigen tests varied with the frequency of RT-PCR testing and prevalence of COVID-19. The sensitivity of antigen testing was 35.7% (95% CI: 17% to 60%) and specificity 99.8% (95% CI: 99.7% to 99.9%) with once-a-week RT-PCR testing after adjusting for school prevalence. Daily antigen testing was similar to RT-PCR testing two to three times a week in identifying infection. Antigen testing identified infection before the next scheduled PCR on 89 occasions and resulted in 234 days where potentially infectious athletes were isolated before they would have been isolated with RT-PCR testing alone. Two athletic-related outbreaks occurred; 86% of total infections were community acquired. CONCLUSION: Antigen testing has high specificity with a short turnaround time but is not as sensitive as RT-PCR. Daily antigen testing or RT-PCR testing two to three times a week is similar. There are benefits and drawbacks to each testing approach.

Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the COVID-19 Pandemic.

CONTEXT: In spring 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. The changes that affected the physical and mental health among young athletes during this time remain unknown. OBJECTIVE: To identify changes in the health (mental health, physical activity, and quality of life) of athletes that occurred during the COVID-19 pandemic. DESIGN: Cross-sectional study. SETTING: Sample recruited via social media. PATIENTS OR OTHER PARTICIPANTS: A total of 3243 Wisconsin adolescent athletes (age = 16.2 ± 1.2 years, 58% female) were surveyed in May 2020 (During COVID-19). Measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n = 5231; age = 15.7 ± 1.2 years, 47% female) collected in 2016 to 2018 (PreCOVID-19). MAIN OUTCOME MEASURE(S): Demographic information included sex, grade, and sport(s) played. Health assessments included the Patient Health Questionnaire-9 Item to identify depression symptoms, the Pediatric Functional Activity Brief Scale to gauge physical activity, and the Pediatric Quality of Life Inventory 4.0 to evaluate health-related quality of life. Univariable comparisons of these variables between groups were conducted via t or χ2 tests. Means and 95% CIs for each group were estimated using survey-weighted analysis-of-variance models. RESULTS: Compared with preCOVID-19 participants, a larger proportion of During COVID-19 participants reported moderate to severe levels of depression (9.7% versus 32.9%, P < .001). Scores of the During COVID-19 participants were 50% lower (worse) on the Pediatric Functional Activity Brief Scale (mean [95% CI] = 12.2 [11.9, 12.5] versus 24.7 [24.5, 24.9], P < .001) and the Pediatric Quality of Life Inventory 4.0 compared with the PreCOVID-19 participants (78.4 [78.0, 78.8] versus 90.9 [90.5, 91.3], P < .001). CONCLUSIONS: During the COVID-19 pandemic, adolescent athletes described increased symptoms of depression, decreased physical activity, and decreased quality of life compared with adolescent athletes in previous years.

SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes.

BACKGROUND: Cardiac involvement among hospitalized patients with severe coronavirus disease 2019 (COVID-19) is common and associated with adverse outcomes. This study aimed to determine the prevalence and clinical implications of COVID-19 cardiac involvement in young competitive athletes. METHODS: In this prospective, multicenter, observational cohort study with data from 42 colleges and universities, we assessed the prevalence, clinical characteristics, and outcomes of COVID-19 cardiac involvement among collegiate athletes in the United States. Data were collected from September 1, 2020, to December 31, 2020. The primary outcome was the prevalence of definite, probable, or possible COVID-19 cardiac involvement based on imaging definitions adapted from the Updated Lake Louise Imaging Criteria. Secondary outcomes included the diagnostic yield of cardiac testing, predictors for cardiac involvement, and adverse cardiovascular events or hospitalizations. RESULTS: Among 19 378 athletes tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 3018 (mean age, 20 years [SD, 1 year]; 32% female) tested positive and underwent cardiac evaluation. A total of 2820 athletes underwent at least 1 element of cardiac triad testing (12-lead ECG, troponin, transthoracic echocardiography) followed by cardiac magnetic resonance imaging (CMR) if clinically indicated. In contrast, primary screening CMR was performed in 198 athletes. Abnormal findings suggestive of SARS-CoV-2 cardiac involvement were detected by ECG (21 of 2999 [0.7%]), cardiac troponin (24 of 2719 [0.9%]), and transthoracic echocardiography (24 of 2556 [0.9%]). Definite, probable, or possible SARS-CoV-2 cardiac involvement was identified in 21 of 3018 (0.7%) athletes, including 15 of 2820 (0.5%) who underwent clinically indicated CMR (n=119) and 6 of 198 (3.0%) who underwent primary screening CMR. Accordingly, the diagnostic yield of CMR for SARS-CoV-2 cardiac involvement was 4.2 times higher for a clinically indicated CMR (15 of 119 [12.6%]) versus a primary screening CMR (6 of 198 [3.0%]). After adjustment for race and sex, predictors of SARS-CoV-2 cardiac involvement included cardiopulmonary symptoms (odds ratio, 3.1 [95% CI, 1.2, 7.7]) or at least 1 abnormal triad test result (odds ratio, 37.4 [95% CI, 13.3, 105.3]). Five (0.2%) athletes required hospitalization for noncardiac complications of COVID-19. During clinical surveillance (median follow-up, 113 days [interquartile range=90 146]), there was 1 (0.03%) adverse cardiac event, likely unrelated to SARS-CoV-2 infection. CONCLUSIONS: SARS-CoV-2 infection among young competitive athletes is associated with a low prevalence of cardiac involvement and a low risk of clinical events in short-term follow-up.

Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19-Related School Closures and Sport Cancellations: A Study of 13 000 Athletes.

CONTEXT: In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of coronavirus disease 2019 (COVID-19). It is critical to understand the mental and physical health of adolescent athletes during this time. OBJECTIVE: To describe the health of athletes during COVID-19-related school closures and sport cancellations. DESIGN: Cross-sectional study. SETTING: A national sample recruited via social media. PATIENTS OR OTHER PARTICIPANTS: A total of 13 002 US adolescent athletes (age = 16.3 ± 1.2 years, females = 52.9%, males = 47.0%) completed an anonymous online survey. MAIN OUTCOME MEASURE(S): Demographic information collected was sex, grade, sport(s) played, and zip code. Assessments used were the General Anxiety Disorder 7-Item for anxiety, Patient Health Questionnaire 9-Item for depression, the Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Mental health, physical activity, and health-related quality-of-life variables were compared among sex, grade, sport(s) played, and poverty level using means and 95% confidence intervals (CIs) from the survey-weighted analysis of variance. RESULTS: Females reported a higher prevalence of moderate to severe anxiety symptoms (females = 43.7% versus males = 28.2%). The Pediatric Functional Activity Brief Scale score was highest (best) for grade 9 (mean = 14.5, 95% CI = 14.0, 15.0) and lowest for grade 11 (mean = 10.9, 95% CI = 10.5, 11.3). The prevalence of depression symptoms was highest in team sport (74.1%) and lowest in individual sport (64.9%) participants. The total Pediatric Quality of Life Inventory score was lowest (worst) for athletes from counties with the highest poverty levels (high: mean = 74.5, 95% CI = 73.7, 75.3; middle: mean = 78.9, 95% CI = 78.0, 79.8; and low: mean = 78.3, 95% CI = 77.4, 79.1). CONCLUSIONS: The health of US adolescents during the COVID-19-related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation, and level of poverty. Health policy experts should consider these findings in the future when creating and implementing policies to improve the health of adolescents in the United States.