BRINGING SCIENCE TO TREATMENT

Post COVID-19 return to sport: an update II

2020;Tennessee Titans wide receiver Corey Davis (84) pulls in a pass as Denver Broncos cornerback A.J. Bouye (21) defends  Credit: Isaiah J. Downing-USA TODAY Sports

With today’s announcement by Louisiana State University’s head football coach Ed Ogeron that ‘most’ of the team has contracted the novel coronavirus, we’ve yet to realize the impact of COVID-19 on athletes fully. Seventy-five of the Texas Tech football team players have also gotten the virus since returning to school for the fall season. While many of those affected with the novel coronavirus return to the gridiron after symptoms resolve, how many suffer silent cardiac damage?

A new study by German physicians may provide insight into the kinds of long-term issues suffered by those with even minor COVID-19 symptoms(1). They conducted a prospective observational cohort study of 100 patient volunteers who tested positive for the novel coronavirus. All subjects had a negative COVID-19 test result and resolution of respiratory symptoms before participation in the study. Fifty-three participants were male, and the mean age (SD) was 49(14) years. Over half of the patients (n=67) recovered at home, and most experienced mild to moderate symptoms. Those with severe symptoms (n=33) underwent hospitalization and more invasive treatment. The COVID-19 positive group also had comorbidities but no history of heart failure or cardiomyopathy.

The investigators compared cardiovascular magnetic resonance imaging (CMR), high-sensitivity troponin T analysis, and N-terminal pro-b-type natriuretic peptides of the COVID-19 sufferers to that of two age-matched and sex-matched control groups. The first group consisted of 50 healthy controls without any evidence of cardiovascular disease. The second control group (n=57) had risk factors for cardiovascular involvement, including hypertension, diabetes, smoking, or other comorbidities.

The median time between the positive COVID-19 test and the CMR was 71 days. Despite the resolution of apparent coronavirus symptoms, over one-third (36%) of the subjects complained of unusual chest pain, palpitations, shortness of breath, and fatigue at the time of the CMR. Twenty-five of them said that basic activities of daily living left them tired, yet only four of this cohort had been ill enough with the coronavirus to warrant hospitalization.

The CMR evaluation revealed that 78% of the subjects showed cardiovascular involvement no matter if they suffered mild symptoms, recovered at home, were severely sick, had a lengthy recovery period before testing, or felt cardiac symptoms. Sixty of the patients showed evidence of myocardial inflammation. Scaring and pericardial effusion were also evident on CMR. Ejection volume and fraction showed changes in the sick participants; however, the findings were not as meaningful as the CMR results.

Practical application

This study reveals that the novel coronavirus can cause inflammation and damage to the heart without producing other severe viral symptoms. In other words, there’s no way to predict the cardiac sequelae from the virus based on the severity of the acute viral course. In addition, the researchers conducted the CMR studies two months or more after the resolution of the virus in half of the subjects. Therefore, the inflammatory findings persist long after the patient tests negative for the virus. Other symptoms also remained in over one-third of the subjects, such as shortness of breath and fatigue.

This study was small and consisted of a mix of COVID-19 presentations from asymptomatic to hospitalized patients. However, the severity of symptoms didn’t account for the 60% of subjects with active cardiac inflammation nor the additional 18% with evidence of other cardiac involvement.

The active cardiac inflammation evident several months after contracting and recovering from the virus is most concerning for athletes returning to sport, especially after a mild illness course where they didn’t feel sick. The temptation is to jump back into playing. However, athletes should strongly consider a complete cardiac evaluation, including a CMR, before resuming their training. If myocarditis is present, guidelines recommend three to six months of relative rest before returning to sport.

Reference

  1. JAMA Cardiol. doi:10.1001/jamacardio.2020.3557
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