Return-to-play guide from experts in the UK

To assist SEM physicians in their medical support of athletes returning to intensive training and competitive sport, this issue of the British Journal of Sports Medicine includes a practical guide by London’s Professor Mathew Wilson et al.4 In a comprehensive, multidisciplinary document, they propose a clear, disease-oriented clinical pathway for cardiac and pulmonary medical decision making to support return to play. Laudable is that Wilson et al also include psychological factors that should be considered in the postlockdown setting where return to play takes place.

They include an integrated flowchart which includes both cardiac and pulmonary considerations. In short, no additional diagnostic steps are recommended in athletes without signs or symptoms of COVID-19. In athletes who were diagnosed with COVID-19, even if the athlete has recovered completely, Wilson and colleagues recommend cardiac evaluation, including a 12-lead ECG and transthoracic echocardiogram. In patients with persistent symptoms (≥14 days), extensive diagnostic testing is recommended, with cardiac MRI as the first-line examination, followed by a cardiopulmonary exercise test and 24-hour Holter monitoring. Pulmonary investigations in athletes with persistent symptoms include a chest X-ray and spirometry. If pulmonary abnormalities or thromboembolic complications are suspected, a CT-scan and a cardiopulmonary exercise test are recommended. If an athlete has been hospitalised, a comprehensive cardiopulmonary evaluation is recommended.

How much is too much (investigation)?

In this logical and stepwise approach for patients who have been diagnosed with COVID-19, potential pulmonary and cardiac COVID-19 sequelae are rigorously investigated. However, as with every screening, in this comprehensive approach hides the risk for overmedicalisation. First, if the ECG, echocardiogram, chest X-ray and spirometry are normal, the diagnostic yield of a cardiopulmonary exercise test is limited to deconditioning, chronic pulmonary embolism or arrhythmias not found during Holter monitoring. Second, there are few specific echocardiographic findings pointing to COVID-19 cardiac involvement, even in individuals with severe disease.5 Third, echocardiographic differentiation between COVID-19 cardiac involvement and cardiac adaptation secondary to sports and exercise is challenging, even in expert settings, when mildly reduced ventricular ejection fractions or ventricular dilatation are found. However, in a non-athlete population, extensive short-term cardiac involvement after COVID-19 has been demonstrated using MRI.6 Whether these findings can be extrapolated to athletes is uncertain. Furthermore, there are currently no data on whether intensive sports and exercise can have a negative impact on outcomes if comparable cardiac involvement is found in athletes. Fortunately, to date, there are no reports of a drastic increase in sudden cardiac arrest or death in elite athletes, neither in peer-reviewed journals nor in mainstream media. Finally, the optimal approach to maximise safety in elite sports would be to establish an international registry with athlete-specific cardiac and pulmonary findings, and long-term consequences of post COVID-19 return to play.

When performing large-scale and comprehensive screenings and investigations, false-positive findings are likely to occur, especially as COVID-19-specific cardiac findings have not yet been reported in the athlete (or generally healthy) population. This could lead not only to a regrettable delay in return to play but also to a cascade of further diagnostic procedures, and the risk of (further) incidental findings. For the elite athlete, the psychological burden of recovery from COVID-19 should also be taken into account, especially if exacerbated by unclear findings.

When considering return to play on a global scale, both the financial burden and the consumption of healthcare resources, in settings where healthcare systems are already under considerable stress from the current pandemic, should be kept in mind. This is especially relevant when performing extensive diagnostic testing in individuals with an asymptomatic or mild course of COVID-19 or with non-specific screening findings.

SEM physicians, with their clinical skills and the benefit of general knowledge across the broad field of SEM,are ideally placed to guide the balance between appropriate diagnostic testing and overmedicalisation. As data accrue on the sequelae of COVID-19 in elite athlete populations, further stratification may become possible—which athletes need which tests and who can safely be cleared for speedy return to sport.

Identifying specific symptoms, signs or findings that are associated with adverse (performance) outcomes will assist in refining management from a disease-oriented approach to a (more customised) symptom-oriented approach; the practical guide by Wilson et al is a first and important step in this direction. With a symptom-oriented approach, there is no demand for highly specialised pulmonary or cardiac expertise for SEM physicians, overmedicalisation is reduced, and the athlete’s perspective remains central.