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When to consider cardiac MRI in the evaluation of the competitive athlete after SARS-CoV-2 infection
  1. Dermot Phelan1,
  2. Jonathan H Kim2,
  3. Jonathan A Drezner3,
  4. Michael D Elliott4,
  5. Matthew W Martinez5,
  6. Eugene H Chung6,
  7. Sheela Krishan7,
  8. Benjamin D Levine8,
  9. Aaron L Baggish9
  1. 1 Sports Cardiology Center, Atrium Health Sanger Heart & Vascular Institute, Charlotte, North Carolina, USA
  2. 2 Sports Cardiology Center, Emory University School of Medicine, Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia, USA
  3. 3 Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
  4. 4 Department of Cardiovascular Medicine, Sanger Heart & Vascular Institute, Charlotte, North Carolina, USA
  5. 5 Atlantic Health, Morristown Medical Center, Morristown, New Jersey, USA
  6. 6 Electrophysiology Program and Sports Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, USA
  7. 7 Sports Cardiology and Fitness Program, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  8. 8 Institute for Exercise and Environmental Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
  9. 9 Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Dermot Phelan, Sports Cardiology Center, Atrium Health Sanger Heart & Vascular Institute, Charlotte, NC 28203, USA; Dermot.Phelan{at}

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Uncertainty regarding the prevalence and clinical implications of myocarditis in athletes after SARS-CoV-2 infection prompted sports medicine and sports cardiology physicians to develop new return-to-play protocols early in the pandemic.1 2 Concern that exercise may exacerbate the severity of cardiac injury and increase the risk of arrhythmic death in those with viral-related myocarditis led to recommendations for more intensive cardiac testing in athletes following SARS-CoV-2 infection, usually, in the USA, with some combination of a resting 12-lead ECG, troponin and transthoracic echocardiogram (so-called ‘triad’ testing). Based solely on expert opinion and rapidly evolving clinical experience, these initial recommendations emphasised the need to gather high-quality data to guide future recommendations.1 2 Early-case series documenting local experiences with cardiac MRI (CMR) in asymptomatic and mildly symptomatic athletes reported high frequencies of cardiac injury.3 These data factored heavily in decisions about restarting sports and even led one sports conference within the National Collegiate Athletic Association to mandate all athletes, whether symptomatic or not, be screened with a CMR.

Recently accrued registry data, now including >5000 professional and collegiate US athletes, provide some clarity regarding the prevalence of cardiac injury (both myocarditis and pericarditis) and the risk of adverse cardiovascular outcomes in athletes following SARS-CoV-2 infection.4–6 Data from the Outcomes Registry for Cardiac Conditions in Athletes (n=3018) and a professional athlete cohort (n=789) document …

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  • Twitter @DermotphelanMD, @jonathankimmd, @DreznerJon

  • Contributors All authors contributed materially to the conception, writing and/or revision of this work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JAD is the editor-in-chief of BJSM.

  • Provenance and peer review Not commissioned; externally peer reviewed.