Outbreaks, Alerts and Hot Topics

COVID-19 From the Heart

Co-author: Brian Harvey, DO | Pediatric Orthopedic Surgery, Pediatric Primary Care; Sports Medicine | Assistant Professor of Surgery, UMKC School of Medicine 

Co-author: Natalie Stork, MD 

Angela Myers, MD, MPH | Director, Division of Infectious Diseases | Professor of Pediatrics, UMKC School of Medicine | Medical Editor, The Link Newsletter

The COVID-19 pandemic brought the world to an unprecedented standstill this past spring and has changed every facet of sports and the game. These changes included the global world of sports, from postponement of the Olympics and professional sports seasons, to the way our local youth practice and participate in sporting activities.

As the world began to emerge back into a new reality, the sports world slowly returned with changes and safeguards in place. With cases continuing to surge, our knowledge of the effects the SARS-CoV-2 virus has on the body continues to grow. Our understanding of presenting symptoms, disease evolution and lingering complications have evolved, along with prevention strategies, vaccine technology and treatment options. While coaches, schools and leagues are tasked with trying to figure out how to safely compete with the lowest risk of transmission, physicians are being tasked with clearing athletes who have been infected with SARS-CoV-2 for a “safe” return to sport. 

Currently, we recognize, the SARS-CoV-2 virus can affect most major organs, including the heart and cardiovascular system. In the adult population, SARS-CoV-2 appears to affect the heart at a higher rate than other viruses. However, data remains limited in the pediatric population.¹ Much of the information in the pediatric population has been generated from patients who have been diagnosed with the more severe disease Multisystem Inflammatory Syndrome in Children (MIS-C) and many have had associated cardiac involvement. Due to limited information on the effect of a mild or moderate COVID-19 illness on the pediatric heart, current recommendations have been made from expert opinion from sports medicine, cardiology and infectious diseases experts, and knowledge gathered from the adult population.

Despite all the progress made in understanding SARS-CoV-2, the effects the virus has on the heart are not fully understood. In the sickest patients, those hospitalized with severe infection or MIS-C, an acute cardiomyopathy or myocarditis can occur.² Myocarditis has been identified in around 28% of adult cases of severe COVID-19 disease. However, the effect a mild or moderate COVID-19 illness has on the cardiovascular system and potential consequences posed to the young athlete are not completely understood. Myocarditis, while acutely affecting the cardiac muscle function, can also lead to more chronic residual scarring and increased risk of ventricular arrhythmias, even after clinical recovery. The most concerning and known sequela of myocarditis is a small, but present risk for sudden cardiac death in the athlete. In addition, there has been concern raised in the athletic community with regard to potential “silent” myocardial inflammation that may occur after a COVID-19 infection and the potential effects, not currently known or understood, this may have on an athlete upon return to training and competition.²

Due to the above concerns, much attention has been focused on which measures can be taken to ensure an appropriate return to sport following a COVID-19 infection. The below recommendations, as mentioned above, are currently based on expert opinion and limited evidence, much of which is extrapolated from the adult population.^1-4

COVID-19 Infection Athletes <12 years old

Asymptomatic COVID-19 Infection – (positive test with no symptoms)

• Consider medical evaluation for any concerns (i.e., past medical history, family history of concerning symptoms) PRIOR to return to activity.
  • If any cardiac concerns (by history or physical exam), obtain an ECG.
• No exercise for at least 10 days from positive test, then may begin light activity.
• The athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Mild COVID-19 Infection – (<4 days of fever >100.4°F, short duration of myalgia, chills and lethargy)

• Athlete should be evaluated by their primary care physician prior to return to activity.
  • If any cardiac concerns (by history or physical exam), obtain ECG.
• No exercise for at least 10 days from symptom onset OR positive test.
• If there are no concerning symptoms, past medical or family history or physical exam findings, may clear for activity.
• The athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Moderate COVID-19 Infection – (4 days of fever >100.4°F, myalgia, chills or lethargy or those who had a non-ICU hospital stay and no evidence of MIS-C)

• Athlete should be evaluated by their primary care physician prior to return to activity.
• No exercise or sport until evaluated by primary care physician.
• Consider ECG with any cardiac concerns (by history of physical exam) OR if the athlete participates in sports more than 2 days per week.
  • If abnormal or any concern, recommend referral to pediatric cardiology prior to return to physical activity or sport.
• If there are no concerning symptoms, past medical history or physical exam findings, may clear for activity.
• The athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Severe COVID-19 Infection – (ICU hospitalization or MIS-C diagnosis)

• Athlete should be evaluated by a pediatric cardiologist prior to return to activity.
• No exercise until further evaluation by a pediatric cardiologist.
• If cleared for activity by cardiology, the athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

COVID-19 Infection Athletes > 12 years old

Asymptomatic COVID-19 Infection – (positive test with no symptoms)

• Athlete should be evaluated by their primary care physician prior to return to activity.
  •  If any cardiac concerns (by history or physical exam), obtain an ECG.
•  No exercise for at least 10 days from positive test, then may begin light activity.
• If there are no concerning symptoms, past medical or family history or physical exam findings, may clear for activity.
• The athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Mild COVID-19 Infection – (<4 days of fever >100.4°F, short duration of myalgia, chills and lethargy)

• Athlete should be evaluated by their primary care physician prior to return to activity.
• Consider ECG if:
  • High school-aged athlete OR
  • If any cardiac concerns (by history or physical exam).
• No exercise for at least 10 days from symptom onset OR positive test.
• If there are no concerning symptoms, past medical or family history or physical exam findings AND any potential test results are normal, may clear for activity.
• The athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Moderate COVID-19 Infection – (4 days of fever >100.4°F, myalgia, chills or lethargy or those who had a non-ICU hospital stay and no evidence of MIS-C)

• Athlete should be evaluated by a pediatric cardiologist prior to return to activity.
• No exercise until further evaluation by a pediatric cardiologist.
• If cleared for activity by cardiology, the athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

Severe COVID-19 Infection – (ICU hospitalization or MIS-C diagnosis)

• Athlete should be evaluated by a pediatric cardiologist prior to return to activity.
• No exercise until further evaluation by a pediatric cardiologist.
• If cleared for activity by cardiology, the athlete should complete a gradual, 7-10 day return to play while observing for any concerning symptoms.*

*Concerning symptoms: chest pain with exercise, shortness of breath, excessive fatigue, palpitations, syncope or near syncope with exercise, decreased exercise tolerance.

While symptoms may vary in how long they take to resolve, likewise, it is important to remember that as athletes return to sport, the time to heal and feel truly conditioned, or back in shape, will take time. Feeling completely ready for sport may take up to double the amount of time they had symptoms, particularly with those in the moderate category.

Special acknowledgement to the Return to Sport COVID task force

• Daniel Forsha, MD, Cardiology
• Nicole Fillingame, Sports Medicine

References:

1. 1. Phelan D, Kim JH, Chung EH. A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiol. 2020.
   2. Baggish A, Drezner JA, Kim J, Martinez M, Prutkin JM. Resurgence of Sport in the Wake of COVID-19: Cardiac Considerations in Competitive Athletes. Br J Sports Med. 2020;54(19):1130-1131.
   3. COVID-19 Interim Guidance: Return to Sports. Services.aap.org. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/. Accessed Jan. 14, 2021.
   4. Dermot Phelan, et al. Screening of Potential Cardiac Involvement in Competitive Athletes Recovering From COVID-19. 2020 JACC: Cardiovascular Imaging 2635-2652, 1312. doi:10.1016/j.jcmg.2020.10.005