PMC Column: Returning to sports after COVID

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MEEKER | Scientia est potentia​.

A division I NCAA basketball player collapses suddenly, is rushed to the emergency room, and is admitted to the hospital in critical condition. Physicians diagnose heart failure and an abnormal heart rhythm – complications of viral  myocarditis (viral infection of the heart muscle). The year is 2006, and 2 weeks prior to  this event, the athlete recovered from a mild cold. Fast forward to December 2020 and  watch a similar scenario unfold, only this time the athlete was diagnosed with COVID-19  several weeks before. 

As we begin ramping back into athletics, a looming question remains…when is it safe for athletes to return after infection? In short, we (the medical community) do not  yet know, and it may be years until we firmly grasp the situation. As information rolls in, expert opinions evolve rapidly. In April of 2020, some cardiologists and expert panels  recommended that no athlete return to sport for a minimum of three months after infection, without exception. In October of 2020, an article published in the Journal of  the American Medical Association: Cardiology (JAMA: Cardiology) recommended a more individualized approach to timelines, screenings, and return to play progressions.  At the time of this writing, there are no established guidelines rooted in large studies to  guide how organizations proceed. Consequently, there is a large diversity in approach  to this risk. For example, some NCAA conferences require a comprehensive cardiac  evaluation for every athlete following a positive COVID test before returning to sport;  and other NCAA conferences take a more individualized approach. Some cardiology opinion articles recommend a comprehensive work up for all athletes, and others recommend no work up unless the athlete had severe enough symptoms to require  hospitalization. Some of these recommendations hedge closer to mitigating all risk regardless of the cost, others lean closer to no additional risk mitigation, and still others attempt to mitigate risk without the expense of unnecessary testing that can increas anxiety, unnecessarily lose playing time, and lead to more unnecessary testing.

After reviewing evidence and reviewing multiple sources of opinion, the providers  at Pioneers Medical Center have decided to take the latter approach. To do so, we have  chosen to follow the guidelines set forth by JAMA: Cardiology in October of 2020. Here  is why. In the medical community, this is what we know so far. COVID can infect the heart muscle leading to myocarditis, and myocarditis is a cause of sudden cardiac death (SCD) in athletes.

Sudden cardiac death in athletes is itself very rare, occuring in 1 out of 40,000 to 80,000 athletes per year. It also has multiple causes including heart structural abnormalities, heart conduction abnormalities, medication side effects, and others, aside from myocarditis. Hypertrophic cardiomyopathy (HOCM) is the leading cause of  SCD, and it is the primary reason physicians listen to your heart during pre-participation  sports physicals.

Myocarditis is also very rare, occurring in 1 to 2 out of 100,000 children per year. Its symptoms range from asymptomatic to overt heart failure requiring hospitalization.  Consequently, it is plausible for athletes to return to sport without knowing they have myocarditis. The most common causes of viral myocarditis are some of the same  viruses leading to the stomach bug, the common cold, influenza, and infectious mononucleosis. Knowing this helps us put the rarity of myocarditis leading to SCD into  perspective. The question is, will COVID significantly lift this from rarity to scary  regularity? Time will tell, but so far, this is what sports cardiologists have to say: 

  • “At present, the prevalence and clinical implications of COVID-19 cardiac pathology in athletes are unknown.” –JAMA Cardiology (October 2020).
  • “Early experience within the sports cardiology community suggests that nearly all athletes, particularly those who have completely recovered from mild COVID-19 infection, do not develop clinically significant COVID-19 CV pathology.” –JAMA Cardiology October, 2020

Subsequently, athletes who have recovered from asymptomatic or mild infection will be recommended to proceed through a multiple stage, individualized progression back into full unrestricted sports participation under either physician or certified athletic  trainer supervision. Athletes who have recovered from moderate or severe illness, or  who have known underlying heart problems, are recommended to undergo a more  comprehensive medical clearance prior to starting the return to play progression. 

More importantly, Pioneers Medical Center and the Meeker schools are working together to help mitigate as much risk as possible in effort to keep our athletes safe. Our plans include a screening process, updating and reviewing emergency action plans,  and ensuring AED’s are in working condition and accessible for all athletic activity,  including both practices and competitive events. The PMC providers have also  corroborated with the pediatric cardiologists at Children’s Hospital in Denver, and we  now have a streamlined process for obtaining answers for athletes requiring cardiac clearance. By combining screening, emergency action plans, AED availability, continually reviewing updated evidence, and maintaining streamlined access to needed  specialists, we can better move forward as a team, mitigating as much risk as possible.

Knowledge is power.

References:
Barry J. Maron, MD, FACC, et al. “Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and other Cardiomyopathies, and Myocarditis.” A Scientific Statement From the American Heart Association and American College of Cardiology. ​Journal of the American Heart Association​. 2015.

Jonathan H. Kim, MD, MSc, et al. “Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play.” ​Journal of the American Medical Association: Cardiology​. October 26, 2020.

Leslie T. Cooper, Jr., M.D. “Myocarditis.” ​ New England Journal of Medicine​. 2009. Richard D. Bagnall, Ph.D., et al. A Prospective Study of Sudden Cardiac Death among Children and Young Adults. New England Journal of Medicine. 2016.