Cardiovascular complications and COVID-19

COVID-19 is a systemic illness that effects most major organs, including the cardiovascular system.3 Clinical experience, largely the care of critically ill patients with COVID-19, has taught us that COVID-19 may affect the heart in at least two fundamental ways. First, the intense ‘cytokine storm’ that develops during severe COVID-19 illness may lead to decrements in cardiac function, similar to those seen in other forms of sepsis, with features that overlap with classic forms of ‘stress’ or catecholamine-induced cardiomyopathy.4 To date, this appears to be a self-limiting phenomenon confined to the severe phases of the illness. Alternatively, COVID-19 may directly infect myocardial cells, leading to myocarditis with lymphocyte-rich inflammatory histology, acute impairment of cardiac muscle function and potentially residual chronic scar with increased vulnerability to malignant ventricular arrhythmias. While COVID-19 myocardial injury, as defined by increases in circulating cardiac troponin levels, has been described in up to 28% of the sickest of patients,5 its prevalence and clinical implications among infected people who experience mild illness or who remain asymptomatic remains completely unknown. Further, the incidence of silent myocardial inflammation that lingers long after the resolution of typical COVID-19 symptoms, a form of disease that may uniquely affect athletes during resumption of training and competition, is also completely unknown.

Cardiac testing in athletes with COVID-19

Numerous medical and sporting organisations are developing comprehensive strategies to ensure a safe return to training and competition. This is a complex process that will require a multidisciplinary, team-based approach that balances priorities surrounding athlete health with strategies to protect the general public from further spread of the infection. Ensuring the health of athletes will involve continued strategic use of physical distancing, widespread dissemination of COVID-19 antigen and antibody testing, the use of electrocardiography or blood biomarker testing to screen for occult myocardial injury and inflammation, and definitive diagnostic and therapeutic strategies for those deemed at highest risk. Evidence is limited, and conclusive recommendations regarding these issues will require ongoing research and monitoring of athletes afflicted with COVID-19. However, we take this opportunity to provide some initial guidance for the cardiac evaluation of athletes with prior COVID-19 infection (table 1).

Trading one preparticipation evaluation (PPE) for another

In lieu of these complexities, we also want to address a simple and well-known strategy that may prove more important than ever before. Oversight of the PPE (not in this case personal protective equipment) is a fundamental responsibility of sport medicine providers.6 From the perspective of heart health, the PPE is traditionally viewed as a tool to screen for occult cardiovascular diseases that predispose the athlete to sudden death. In the wake of COVID-19, it will be prudent to adopt a broader view of the cardiovascular PPE. In addition to using the PPE to search for rare genetic and congenital conditions, we will be best positioned to facilitate safe return to sport if we also use the PPE to screen for cardiovascular sequelae of COVID-19. Though imperfect, medical history and physical examination may prove to be valuable tools for identifying athletes with underlying myocardial inflammation and/or overt myocarditis. In addition, practitioners and organisations that are experienced and resourced in the use of 12-lead electrocardiography will optimise this screening adjunct by keeping a keen eye out for patterns reflective of myocardial inflammation, such as T-wave inversions and new ST segment changes.7 This can and will help to identify those athletes that may require additional testing and medical care prior to return to play.

The resumption of competitive athletics will bring great joy but will come with considerable challenge and additional efforts to ensure cardiac safety. There are fundamental questions about how COVID-19 will leave its mark on the millions of athletes worldwide and what steps should be taken to prevent further unnecessary loss of life. While these questions will be asked by the men and women on the front lines of athlete care, they will only be answered by the sharing of experiences and the pooling of rigorously collected data. If done effectively, the connotation of the acronym PPE will once again relate solely to the PPE rather than to the use of surgical masks and face shields that have defined this pandemic.