Doctors recommend cardiac screening tests for competitive athletes who have recovered from Covid-19 after a small study found heart damage in 1 in 7 college sports competitors, including in those whose coronavirus infection caused no obvious symptoms.
Cardiac magnetic resonance imaging on 26 competitive college athletes who had either a mild or asymptomatic SARS-CoV-2 infection found four, or 15%, with signs of inflammation of the heart muscle. These suspected myocarditis patients were males in their late teens and early 20s, including two who experienced no Covid-19 symptoms, doctors at Ohio State University in Columbus reported Friday in a research letter to the Journal of the American Medical Association.
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The finding adds to a growing body of evidence that the pneumonia-causing coronavirus is also resulting in damage to the heart, as well as other organs. While little is known about the long-term cardiac consequences, screening for heart complications may identify people at risk of further injury, the researchers said.
"Myocarditis is a significant cause of sudden cardiac death in competitive athletes," Saurabh Rajpal, an assistant professor of internal medicine, and colleagues wrote. "Cardiac magnetic resonance imaging has the potential to identify a high-risk cohort for adverse outcomes and may, importantly, risk-stratify athletes for safe participation."
Evidence of myocardial inflammation seen on cardiac MRI scans has been associated "with poor outcomes, including myocardial dysfunction and mortality," the authors said. Athletes with probable myocarditis should be asked to rest for three months to recover, based on current guidelines, Rajpal said in an email. Additional research is needed to determine whether that can prevent further injury, he said.
None of the athletes - who were football, soccer, lacrosse, basketball, and track competitors - had known heart disease when they underwent post-Covid testing. An additional eight athletes, or 31%, showed signs of prior heart-muscle insult which, Rajpal said, may also have been the result of athletic cardiac adaptation. Highly trained endurance athletes are 10 times more likely than non-athletes to have signs of heart stress, a cardiac MRI study last week found.
The Ohio study wasn't designed to identify the prevalence or risk of myocardial injury in athletes with a recent history of SARS-CoV-2 infection, Rajpal said. Further studies are planned in which athletes not affected by the coronavirus will also be assessed for comparison. More research is also needed to understand the long-term consequences of Covid-19 on the hearts of young athletes, he said.
Concerns about still unknown health effects caused two major collegiate athletic conferences in the U.S. to halt their upcoming sports seasons. Others have pressed forward. College football is already underway and professional football started its season Thursday night.
The American College of Cardiology's Sports and Exercise Cardiology Council in May developed guidelines for letting athletes return to play. They vary based on the severity of a person's illness, recommending anyone who tests positive to rest for two weeks and those who experienced mild or severe symptoms to be evaluated by a medical professional.
However, emerging knowledge and cardiovascular MRI observations "question this recommendation," the Ohio researchers said.
Though most cases of myocarditis result in "a good degree of recovery," some patients will suffer scarring and potentially severe complications, said Garry Jennings, a cardiologist and executive director of Sydney Health Partners, an Australian medical research group. Longer-term problems include abnormal heart rhythms, chronic heart failure and even sudden death.
Jennings recommends that athletes who test positive for SARS-CoV-2 without Covid-19 symptoms rest for two weeks then undergo a medical check-up before resuming training.
"Depending on the level of exercise, they need to go slow and increase gradually and obviously report any symptoms," he said. "For people with more moderate or severe Covid, you need to be much more conservative than that."
Ideally, such athletes should undergo cardiac imaging, plus a blood test for troponin - which may indicate heart-muscle damage - to rule out ongoing myocardial damage that would predispose the heart to additional strain, Jennings said.
Worries around heart inflammation and other possible side effects are dominating conversations with athletes, said Julia Iafrate, an assistant professor of rehabilitation and regenerative medicine and director of dance medicine at Columbia University in New York. Iafrate tries to remind people that they are seeing research unfold in real time and what is accurate today might not be accurate in a few months time, she said.
A study in July of 100 recently recovered Covid-19 patients in Germany found that more than three-quarters experienced some heart problems and 60% suffered ongoing myocardial inflammation, regardless of any preexisting conditions and the severity of their coronavirus infection.
The risk may extend to infants, too. Doctors in Ankara reported direct SARS-CoV-2 damage last month in a fatal case of viral myocarditis in a 2-year-old otherwise healthy boy.
Being young and healthy is not a reason to brush off the novel coronavirus, Iafrate said. "We know you're better off not getting Covid," she said.