The risk of myocarditis after COVID-19 might kill fall sports

I’ve been going back and forth on the likelihood we will have fall sports due to the COVID-19 pandemic. You can read my previous articles debating different aspects of the virus and return-to-play issues. This week, the biggest challenge to sports – at least for high school and college athletes who aren’t paid to play and paid to accept the risks of playing during the pandemic – presented itself. In my latest newspaper column, I discuss myocarditis and how complex determining which athletes are at risk could be.

The risk of the new coronavirus and COVID-19 infection on an athlete’s heart could end fall sports before they begin.

Reports of athletes with myocarditis threaten college sports

On Monday, Paula Lavigne and Mark Schlabach of ESPN reported that an inflammation of heart muscle called myocarditis has been detected in at least five Big Ten Conference athletes and athletes in other conferences. The uncertainty about the long-term outcomes of athletes with myocarditis after COVID-19 has led to meetings among school presidents, chancellors and athletic directors, as well as conference commissioners and health advisory board members, which could result in the postponement of fall collegiate sports.

Also read:
Professional sports return amid COVID-19

What is myocarditis?

An athlete with myocarditis commonly presents with shortness of breath with physical exertion, chest pain, and heartbeat irregularities. It can also present like a heart attack with sudden death. And myocarditis can lead to sudden death without the athlete showing symptoms ahead of time.

What we don’t know about COVID-19 and myocarditis among athletes

Unfortunately, there is much we don’t know about COVID-19 and myocarditis. We have limited data of how common people who are not hospitalized with COVID-19 have cardiac injury from the virus or the long-term outcomes of that heart damage the infection can cause.

Also read:
The opinions of college football players should factor into the decision about playing during the COVID-19 pandemic

In a July study published in JAMA Cardiology, researchers used cardiovascular MRI to study the hearts of patients who had recently recovered from COVID-19. They found 60 percent had myocardial inflammation. But the median age of patients in that study was 49, not the 14- to 21-year-olds who play high school and college sports.

Return to play sports after myocarditis

If an athlete develops myocarditis, whether from COVID-19 or some other virus, the guidelines for his or her return to sports are fairly straightforward. The American Heart Association and American College of Cardiology recommend that the athlete should undergo a number of tests of heart function no sooner than 3 to 6 months after a diagnosis of myocarditis, and he or she cannot return to sports until those tests are normal.

Also read:
Why I now believe there will be fall sports in the U.S. despite COVID-19

Return to play sports after COVID-19 – Assessing cardiac risk

The more difficult question pertains to how to best identify myocarditis in COVID-19-positive athletes with no shortness of breath, chest pain, or heart arrhythmias. In May, members of the American College of Cardiology’s Sports & Exercise Cardiology Council issued guidelines for these athletes.

Athletes who test positive for COVID-19 but who show no symptoms from the virus should refrain from exercise and sports training for at least two weeks from the date of positive test result.

Athletes who test positive for COVID-19 who develop mild or moderate symptoms should stop all exercise and sports training for a minimum of two weeks after the symptoms completely resolve. The guidelines also recommend these athletes undergo cardiovascular testing. Only when the athlete has no symptoms and the tests show no cardiac involvement should he or she return to training.

Also read:
How will COVID-19 affect sports in the fall?

How some schools are screening athletes for heart injury from COVID-19

In reading the ESPN article, it’s striking how some Power 5 schools’ medical teams are evaluating the heart risks for COVID-19 athletes. For example, doctors covering the University of Washington teams are not just screening for heart symptoms, but they are obtaining electrocardiograms, heart ultrasounds, and measuring blood levels for proteins that show heart injury. In some cases, they have the athlete undergo a cardiac MRI.

One wonders whether smaller colleges and universities, or high schools, have the resources to thoroughly screen COVID-19 athletes for myocarditis. The uncertainty of the long-term effects of heart injury and the complexity of determining which athletes are at risk might be enough to stop fall sports.

Note: A modified version of this article appears as my sports medicine column in the August 13, 2020 issue of The Post and Courier.

References:
Heart condition linked with COVID-19 fuels Power 5 concern about season’s viability. By Paula Lavigne and Mark Schlabach. ESPN.com. August 10, 2020.

Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol.  Published online July 27, 2020.

A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiol.  Published online May 13, 2020.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis. Circulation. November 2, 2015.