Table 1

Cardiac evaluation in athletes with prior COVID-19 infection

Clinical scenarioRecommended assessmentComments
Athletes with prior asymptomatic infection as confirmed antibody to severe acute respiratory syndrome coronavirus 2 Focused medical history and physical examination to screen for findings newly emergent in the COVID-19 era
Consider 12-lead ECG*
  • If ECG is abnormal or shows new repolarisation changes compared with a prior ECG, then additional evaluation with minimum echocardiogram and exercise test is warranted in conjunction with a sports cardiologist.

  • Myopericarditis related to COVID-19 should be considered in patients with a history of new-onset chest pain/pressure (even in the absence of fever and respiratory symptoms), palpitations or exercise intolerance.

  • Comprehensive clinical evaluation, regardless of ECG findings, is indicated in athletes with new-onset cardiovascular symptoms or exercise intolerance.

Athletes with a history of mild illness (non-hospitalised) related to confirmed or suspected COVID-19 Focused medical history and physical examination to screen for persistent or new postinfectious findings following COVID-19 infection
Perform 12-lead ECG*
  • If ECG is abnormal or shows new repolarisation changes compared with a prior ECG, then additional individualised evaluation is warranted, including at minimum echocardiography and exercise testing, in conjunction with a sports cardiologist.

  • ECG findings that may indicate viral-induced myocardial injury include pathological Q waves, ST segment depression, (new) diffuse ST segment elevation and T-wave inversion.

  • Comprehensive clinical evaluation, regardless of ECG findings, is indicated in athletes with new-onset cardiovascular symptoms or exercise intolerance.

Athletes with a history of moderate to severe illness (hospitalised) related to confirmed or suspected COVID-19 Comprehensive evaluation prior to return to sport, in conjunction with a sports cardiologist, to include blood biomarker assessment (ie, hs-Tn and NP), 12-lead ECG, echocardiography, exercise testing and ambulatory rhythm monitoring
  • Myocardial injury is more likely in patients with a more severe disease course, and normal cardiac function and exercise tolerance should be established prior to a return to exercise.

  •  Cardiac MRI may be considered based on clinical suspicion of myocardial injury.†

Athletes with a history of COVID-19 infection (regardless of severity) and documented myocardial injury as indicated by one or more of the following: in-hospital ECG changes, hs-Tn or NP elevation, arrhythmia or impaired cardiac function Comprehensive evaluation prior to return to sport, in conjunction with a sports cardiologist, to include blood biomarker assessment (ie, hs-Tn and NP), 12-lead ECG, echocardiography, exercise testing, ambulatory rhythm monitoring and cardiac MRI.†
  •  Return to training should be gradual and under the supervision of a cardiologist.

  •  Longitudinal follow-up, including serial cardiac imaging, may be required in athletes with initially abnormal cardiac function.

  • *ECG as a screening test to exclude myocarditis is limited. ECG in patients with myocarditis may be normal or may show non-specific abnormalities. Additional evaluation may be warranted based on clinical suspicion.

  • †Cardiac MRI should be performed with gadolinium to assess for myocardial scar and LGE. The presence of LGE is associated with a higher risk of major adverse cardiovascular events.

  • hs-Tn, high-sensitivity cardiac troponin; LGE, late gadolinium enhancement; NP, natriuretic peptide.