Diagnosing COVID-19 myocarditis in athletes using cMRI.

An early report during the SARS-CoV-2 (COVID-19) outbreak noted myocardial involvement with cardiac troponin I (cTnI) levels >99th percentile in approximately 20% of hospitalized patients. Patients with cTnI elevations had higher in-hospital mortality. Additionally, myocarditis is associated with exercise-related sudden cardiac death in athletes. Therefore, reports of COVID-19 myocarditis concerned the sports cardiology community, which issued two guidelines on managing athletes with COVID-19 infection. We reviewed reports of myocardial involvement in athletes after COVID-19 infection published before June 2021. The incidence of the diagnosis of myocarditis in athletes post-COVID-19 ranged from 0 to 15.4% based on cardiac magnetic resonance imaging (cMRI) performed 10 to 194 days after initial diagnosis of COVID-19. Only a few studies adhered to accepted myocarditis diagnostic guidelines and only two studies included a control group of uninfected athletes. There was significant heterogeneity in the method and protocols used in evaluating athletes post-COVID-19. The incidence of COVID-19 myocarditis in athletes appears to be over-diagnosed. The evaluation of myocarditis post-COVID-19 should be individually performed and managed according to the current guidelines. This can potentially prevent needless training restrictions and the inability to participate in competitive sports.

Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play.

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.