A prospective study on the consequences of SARS-CoV-2 infection on the heart of young adult competitive athletes: Implications for a safe return-to-play

A Systematic Review and Meta-Analysis on Aerobic Fitness Dynamics in Post-COVID-19 Athletes: Implications in the Return-to-Play Performance

Maximal oxygen uptake (V.O2max) assesses athletic performance; however, its values are inconsistent in post-COVID-19 athletes. This study aimed to analyze the dynamics of V.O2max in post-COVID-19 athletes. Observational studies were identified by screening the PubMed database published up to 17 July 2023. The initial electronic search found 320 studies. Of these, 26 employing the cardiopulmonary exercise test (CPET) to assess aerobic fitness were selected. Of the 2625 pooled athletes, 1464 were infected and considered as the post-COVID-19 group, either asymptomatic or symptomatic, while the remaining 1161, who were uninfected or had V.O2max results prior to infection, were defined as the infection-free group. Age and V.O2max were differently distributed between post-COVID-19 athletes and those without infection (p = 0.03 in both). Persistent symptoms athletes had 8 mL/Kg/min lower V.O2max than those without infection (p = 0.04). In addition, post-infected athletes who underwent CPET after 12 weeks showed a significant reduction of 2.9 mL/Kg/min in V.O2max according to the increase in body mass index (BMI). The pooled analysis showed that aerobic fitness was reduced in athletes post-COVID-19. V.O2max was negatively correlated with BMI in those who underwent CPET at 12 weeks, suggesting that symptoms persist beyond 12 weeks, affecting return-to-play.

Systematic Review of COVID-19 and COVID-19 mRNA Vaccine Myocarditis in Athletes: Incidence, Diagnosis, Prognosis, and Return-to-Play Principles

OBJECTIVE

The purpose of this systematic review is to evaluate the original peer-reviewed studies on athletes who developed myocarditis after coronavirus disease (COVID-19) infection or after COVID-19 mRNA vaccination. Both entities likely have an immunologic component. We discuss elite, professional, college, and adolescent athletes. The athletes are generally young and healthy, representing a distinctive population group that differs from the general population. This review includes diagnosis of myocarditis, incidence, complications, prognosis, and return-to-play guidance for sports medicine clinicians and coaches.

DATA SOURCES

We surveyed the PUBMED, Embase, and Web of Science databases for the relevant peer-reviewed articles in the English language published from the onset of the pandemic until April 2023. Included were original observational studies and case series. Excluded were individual case reports and a small series with incomplete data. The resulting search yielded 30 original articles.

MAIN RESULTS

Reported myocardial abnormalities in athletes were rare after COVID-19 infection and even less frequent after COVID-19 mRNA vaccination. True incidence, however, may be higher because of under-reporting and frequent asymptomatic presentation. Male gender was prevalent for both manifestations; postvaccination myocarditis occurrence was the highest after the second vaccine dose. Diagnostic and return-to-play algorithms were developed and should be adopted and followed.

CONCLUSIONS

The risk of myocarditis from COVID-19 infection and COVID-19 mRNA vaccination is very low. The long-term prognosis and evolution of the observed cardiac magnetic resonance abnormalities are currently unknown. Although inferences can be made from the published data, COVID-19 and postvaccine myocarditis in athletes may represent only a small fraction of the true incidence of those who have been affected worldwide and not evaluated.

Return-to-Play Post-COVID-19 in 2023: A Pediatric Case Report

As pediatric-focused nurse practitioners continue to grapple with the impact the COVID-19 pandemic has had on youth since 2020, they are simultaneously faced with navigating what it looks like to ensure the success and health of children moving forward from the pandemic. Despite the relaxation of COVID-19 guidelines in many schools and athletic programs across the country, ensuring a safe return-to-play post-COVID-19 infection must continue to be a priority for pediatric-focused nurse practitioners. Here, we present the case of a 13-year-old female who was seen in a primary care clinic after reporting dizziness and shortness of breath with activity post-COVID-19 infection. After further workup, it was determined her symptoms were most consistent with shortness of breath and dizziness related to coughing induced by activity.

Determinants of cardiorespiratory fitness measured by cardiopulmonary exercise testing in COVID-19 survivors: a systematic review with meta-analysis and meta‑regression

BACKGROUND

The relationship between cardiorespiratory fitness and its possible determinants in post-COVID-19 survivors has not been systematically assessed.

OBJECTIVES

To identify and summarize studies comparing cardiorespiratory fitness measured by cardiopulmonary exercise testing in COVID-19 survivors versus non-COVID-19 controls, as well as to determine the influence of potential moderating factors.

METHODS

We conducted a systematic search of MEDLINE/PubMed, Cochrane Library, EMBASE, Google Scholar, and SciELO since their inceptions until June 2022. Mean differences (MD), standard mean differences (SMD), and 95% confidence intervals (CI) were calculated. Subgroup and meta-regression analyses were used to evaluate potential moderating factors.

RESULTS

48 studies (3372 participants, mean age 42 years, and with a mean testing time of 4 months post-COVID-19) were included, comprising a total of 1823 COVID-19 survivors and 1549 non-COVID-19 controls. After data pooling, VO2 peak (SMD=1.0 95% CI: 0.5, 1.5; 17 studies; N = 1273) was impaired in COVID-19 survivors. In 15 studies that reported VO2 peak values in mL/min/kg, non-COVID-19 controls had higher peak VO2 values than COVID-19 survivors (MD=6.2, 95% CI: 3.5, 8.8; N = 905; I2=84%). In addition, VO2 peak was associated with age, time post-COVID-19, disease severity, presence of dyspnea, and reduced exercise capacity.

CONCLUSION

This systematic review provides evidence that cardiorespiratory fitness may be impaired in COVID-19 survivors, especially for those with severe disease, presence of dyspnea, and reduced exercise capacity. Furthermore, the degree of reduction of VO2 peak is inversely associated with age and time post-COVID.

Return to play of young and adult professional athletes after COVID-19: A scoping review

Background/objective

Given the persistence of COVID-19 under various facets and mutations, there is an urgent need to understand the debate on a safe return to play for professional athletes (young and adults) recovering from the infection. This work offers a scoping and comprehensive review on the topic during the first two years of the pandemic event by providing an identification of main clusters of research, relevant gaps and significant insights for future investigation.

Methods

The literature is selected using the search engines of: PubMed®, SCIENCEDIRECT, and SCOPUS. Further criteria for selection are: Time range of 2020-2022; Scope: Return to play of professional athletes recovering from COVID-19 infection; 3) Types of publications: Research papers, reviews, practice guidelines, case reports; 4) Language: English. Two independent researchers performed a quality check on a random sample (n = 30%) of publications.

Results

Main results reveal four research clusters deepening the analysis on: myocarditis, cardiac diseases and return to play, training and rehabilitation, mass screening and risk assessment, and sport and bio-psycho-social sphere for a safe return to play. Major collaborations occur between UK-South Africa, UK-USA, USA-Canada, and USA-Australia.

Conclusions

Important gaps refer to a lack of investigation on a safe return to play for female athletes in mostly all sports disciplines; on the other hand, sport and the bio-psycho-social sphere of the athlete is a fast-growing topic. Both deserve further attention in the immediate future to improve ad-hoc sport and exercise practices.

COVID-19 in Female and Male Athletes: Symptoms, Clinical Findings, Outcome, and Prolonged Exercise Intolerance-A Prospective, Observational, Multicenter Cohort Study (CoSmo-S)

BACKGROUND

An infection with SARS-CoV-2 can lead to a variety of symptoms and complications, which can impair athletic activity.

OBJECTIVE

We aimed to assess the clinical symptom patterns, diagnostic findings, and the extent of impairment in sport practice in a large cohort of athletes infected with SARS-CoV-2, both initially after infection and at follow-up. Additionally, we investigated whether baseline factors that may contribute to reduced exercise tolerance at follow-up can be identified.

METHODS

In this prospective, observational, multicenter study, we recruited German COVID elite-athletes (cEAs, n = 444) and COVID non-elite athletes (cNEAs, n = 481) who tested positive for SARS-CoV-2 by PCR (polymerase chain reaction test). Athletes from the federal squad with no evidence of SARS-CoV-2 infection served as healthy controls (EAcon, n = 501). Questionnaires were used to assess load and duration of infectious symptoms, other complaints, exercise tolerance, and duration of training interruption at baseline and at follow-up 6 months after baseline. Diagnostic tests conducted at baseline included resting and exercise electrocardiogram (ECG), echocardiography, spirometry, and blood analyses.

RESULTS

Most acute and infection-related symptoms and other complaints were more prevalent in cNEA than in cEAs. Compared to cEAs, EAcon had a low symptom load. In cNEAs, female athletes had a higher prevalence of complaints such as palpitations, dizziness, chest pain, myalgia, sleeping disturbances, mood swings, and concentration problems compared to male athletes (p < 0.05). Until follow-up, leading symptoms were drop in performance, concentration problems, and dyspnea on exertion. Female athletes had significantly higher prevalence for symptoms until follow-up compared to male. Pathological findings in ECG, echocardiography, and spirometry, attributed to SARS-CoV-2 infection, were rare in infected athletes. Most athletes reported a training interruption between 2 and 4 weeks (cNEAs: 52.9%, cEAs: 52.4%), while more cNEAs (27.1%) compared to cEAs (5.1%) had a training interruption lasting more than 4 weeks (p < 0.001). At follow-up, 13.8% of cNEAs and 9.9% of cEAs (p = 0.24) reported their current exercise tolerance to be under 70% compared to pre-infection state. A persistent loss of exercise tolerance at follow-up was associated with persistent complaints at baseline, female sex, a longer break in training, and age > 38 years. Periodical dichotomization of the data set showed a higher prevalence of infectious symptoms such as cough, sore throat, and coryza in the second phase of the pandemic, while a number of neuropsychiatric symptoms as well as dyspnea on exertion were less frequent in this period.

CONCLUSIONS

Compared to recreational athletes, elite athletes seem to be at lower risk of being or remaining symptomatic after SARS-CoV-2 infection. It remains to be determined whether persistent complaints after SARS-CoV-2 infection without evidence of accompanying organ damage may have a negative impact on further health and career in athletes. Identifying risk factors for an extended recovery period such as female sex and ongoing neuropsychological symptoms could help to identify athletes, who may require a more cautious approach to rebuilding their training regimen.

TRIAL REGISTRATION NUMBER

DRKS00023717; 06.15.2021-retrospectively registered.

The Impact of the SARS-COVID-19 Lockdowns on the Subjectively Perceived Performance Level of Amateur Athletes after Returning to the Gyms

Since December 2019, few issues have garnered as much global attention as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-19). The imposed lockdowns in 2020/21, which led to the closure of all gyms, barred people from participating in their favourite sports activities. This study explores athletes' self-evaluations of their performance levels upon return to training facilities post-reopening. Data were collected in May 2021, after the end of the second lockdown, using a national online questionnaire. The study recorded 20 demographic and training-specific parameters to discern the factors influencing self-perceived performance upon resuming gym activities after the 2020/2021 lockdown. A total of 1378 respondents participated in the study. Of the total number of participants, 27.5% (365) reported regaining 100% of their original performance level after reopening their studios, a proportion that comprised 212 males, 150 females, and 3 individuals of unspecified gender. Additionally, 35.7% (474) estimated their performance level to be up to 75%, followed by 30% (398) recording their performance level at 50%, and a minority of 6.8% (90) determining their performance level to be up to 25%. Exercise intensity prior to lockdown, training experience, sex, and concurrent practice of another sport significantly influenced the athletes' self-assessment of their current fitness levels (p > 0.001, p > 0.001, p > 0.001, and 0.006, respectively). We need to understand the factors that shape self-perception, especially in case of another lockdown, in order to provide preventive assistance concerning mental and physical well-being. Positive influences on self-perception include prior athletic experience, intensive training before the lockdown, and continued participation in sports throughout the lockdown. Younger age is also favourable, but this may not necessarily reflect the benefits of youth; rather, it could indicate the current lack of accessible online sports activities for older individuals. Women, however, might have a less favourable perception of their own athletic performance.

Echocardiographic findings in non-hospitalised children and adolescents following acute COVID-19

BACKGROUND

Although COVID-19 is known to have cardiac effects in children, seen primarily in severe disease, more information is needed about the cardiac effects following COVID-19 in non-hospitalised children and adolescents during recovery. This study aims to compare echocardiographic markers of cardiac size and function of children following acute COVID-19 with those of healthy controls.

METHODS

This single-centre retrospective case-control study compared 71 cases seen in cardiology clinic following acute COVID-19 with 33 healthy controls. Apical left ventricle, apical right ventricle, and parasternal short axis at the level of the papillary muscles were analysed to measure ventricular size and systolic function. Strain was analysed on vendor-independent software. Statistical analysis was performed using t-test, chi-square, Wilcoxon rank sum, and regression modelling as appropriate (p < 0.05 significant).

RESULTS

Compared to controls, COVID-19 cases had slightly higher left ventricular volumes and lower left ventricular ejection fraction and right ventricular fractional area change that remained within normal range. There were no differences in right or left ventricular longitudinal strain between the two groups. Neither initial severity nor persistence of symptoms after diagnosis predicted these differences.

CONCLUSIONS

Echocardiographic findings in children and adolescents 6 weeks to 3 months following acute COVID-19 not requiring hospitalisation were overall reassuring. Compared to healthy controls, the COVID-19 group demonstrated mildly larger left ventricular size and lower conventional measures of biventricular systolic function that remained within the normal range, with no differences in biventricular longitudinal strain. Future studies focusing on longitudinal echocardiographic assessment of patients following acute COVID-19 are needed to better understand these subtle differences in ventricular size and function.

The athlete after COVID-19 infection: what the scientific evidence? What to do? A position statement

The Coronavirus-19 disease (COVID-19) related pandemic have deeply impacted human health, economy, psychology and sociality. Possible serious cardiac involvement in the infection has been described, raising doubts about complete healing after the disease in many clinical settings. Moreover, there is the suspicion that the vaccines, especially those based on mRNA technology, can induce myopericarditis. Myocarditis or pericarditis related scars can represent the substrate for life-threatening arrhythmias, triggered by physical activity. A crucial point is how to evaluate an athlete after a COVID-19 infection ensuring a safe return to play without increasing the number of unnecessary disqualifications from sports competitions. The lack of conclusive scientific data significantly increases the difficulty to propose recommendations and guidelines on this topic. At the same time, the psychological and physical negative consequences of unnecessary sports restriction must be taken into account. The present document aims to provide an updated brief review of the current knowledge about the COVID-19 cardiac involvement and how to recognize it and to offer a roadmap for the management of the athletes after a COVID-19 infections, including subsequent impact on exercise recommendations. Our document exclusively refers to cardiovascular implications of the disease, but pulmonary consequences are also considered.

Long-term cardiac follow-up of athletes infected with SARS-CoV-2 after resumption of elite-level sports

OBJECTIVE

Longitudinal consequences and potential interactions of COVID-19 and elite-level sports and exercise are unclear. Therefore, we determined the long-term detrimental cardiac effects of the interaction between SARS-CoV-2 infection and the highest level of sports and exercise.

METHODS

This prospective controlled study included elite athletes from the Evaluation of Lifetime participation in Intensive Top-level sports and Exercise cohort. Athletes infected with SARS-CoV-2were offered structured, additional cardiovascular screenings, including cardiovascular MRI (CMR). We compared ventricular volumes and function, late gadolinium enhancement (LGE) and T1 relaxation times, between infected and non-infected elite athletes, and collected follow-up data on cardiac adverse events, ventricular arrhythmia burden and the cessation of sports careers.

RESULTS

We included 259 elite athletes (mean age 26±5 years; 40% women), of whom 123 were infected (9% cardiovascular symptoms) and 136 were controls. We found no differences in function and volumetric CMR parameters. Four infected athletes (3%) demonstrated LGE (one reversible), compared with none of the controls. During the 26.7 (±5.8) months follow-up, all four athletes resumed elite-level sports, without an increase in ventricular arrhythmias or adverse cardiac remodelling. None of the infected athletes reported new cardiac symptoms or events. The majority (n=118; 96%) still participated in elite-level sports; no sports careers were terminated due to SARS-CoV-2.

CONCLUSIONS

This prospective study demonstrates the safety of resuming elite-level sports after SARS-CoV-2 infection. The medium-term risks associated with SARS-CoV-2 infection and elite-level sports appear low, as the resumption of elite sports did not lead to detrimental cardiac effects or increases in clinical events, even in the four elite athletes with SARS-CoV-2 associated myocardial involvement.

Respiratory complications following COVID-19 in athletic populations: A narrative review

Athletes typically experience a mild-to-moderate, self-limiting illness following infection with the novel severe acute respiratory syndrome coronavirus 2. Some athletes, however, can develop prolonged symptoms, with breathlessness, cough, and chest tightness impacting return to training and competition. In athletes with persistent cardiopulmonary symptoms following COVID-19, focus is usually placed on the identification and characterization of cardiac complications, such as myocarditis. In this review, we focus on summarizing the literature assessing pulmonary complications and physiological consequences associated with COVID-19 illness in athletes. The review also provides recommendations for clinical assessment of the athlete with pulmonary issues following COVID-19 and directions for future research.

Myocarditis Screening Methods in Athletes After SARS-CoV-2 Infection - a Systematic Review

This review aims to elucidate the myocarditis incidence in SARS-CoV-2-positive athletes and to evaluate different screening approaches to derive sports cardiological recommendations after SARS-CoV-2 infection. The overall incidence of athletes (age span 17-35 years, 70% male) with myocarditis after SARS-CoV-2 infection was 1.2%, with a high variation between studies (which contrasts an incidence of 4.2% in 40 studies within the general population). Studies that used conventional screening based on symptoms, electrocardiogram, echocardiography, and cardiac troponin - only followed by cardiac magnetic resonance imaging in case of abnormal findings - reported lower myocarditis incidences (0.5%, 20/3978). On the other hand, advanced screening that included cardiac magnetic resonance imaging within the primary screening reported higher incidences (2.4%, 52/2160). The sensitivity of advanced screening seems to be 4.8 times higher in comparison to conventional screening. However, we recommend prioritization of conventional screening, as the economical load of advanced screening for all athletes is high and the incidence of myocarditis in SARS-CoV-2-positive athletes and the risk of adverse outcomes seems low. Future research will be important to analyze the long-term effects of myocarditis after infection with SARS-CoV-2 in athletes for risk stratification to optimally guide a safe return to sport.

Periodic health evaluation in athletes competing in Tokyo 2020: from SARS-CoV-2 to Olympic medals

Background

The Tokyo Olympic games were the only games postponed for a year in peacetime, which will be remembered as the COVID-19 Olympics. No data are currently available on the effect on athlete's performance.

Aim

To examine the Italian Olympic athletes who have undergone the return to play (RTP) protocol after COVID-19 and their Olympic results.

Methods

642 Potential Olympics (PO) athletes competing in 19 summer sport disciplines were evaluated through a preparticipation screening protocol and, when necessary, with the RTP protocol. The protocol comprised blood tests, 12-lead resting ECG, transthoracic echocardiogram, cardiopulmonary exercise test, 24-hour Holter-ECG monitoring and cardiovascular MR based on clinical indication.

Results

Of the 642 PO athletes evaluated, 384 participated at the Olympic Games, 254 being excluded for athletic reasons. 120 athletes of the total cohort of 642 PO were affected by COVID-19. They were evaluated with the RTP protocol before resuming physical activity after a mean detraining period of 30±13 days. Of them, 100 were selected for Olympic Games participation, 16 were excluded for athletic reasons and 4 were due to RTP results (2 for COVID-19-related myocarditis, 1 for pericarditis and 1 for complex ventricular arrhythmias). Among athletes with a history of COVID-19 allowed to resume physical activity after the RTP and selected for the Olympic Games, no one had abnormalities in cardiopulmonary exercise test parameters, and 28 became medal winners with 6 gold, 6 silver and 19 bronze medals.

Conclusions

Among athletes with COVID-19, there is a low prevalence of cardiac sequelae. For those athletes allowed to resume physical activity after the RTP evaluation, the infection and the forced period of inactivity didn't have a negative impact on athletic performance.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

The utility of cardiopulmonary exercise testing in athletes and physically active individuals with or without persistent symptoms after COVID-19

Introduction

Cardiopulmonary exercise testing (CPET) may capture potential impacts of COVID-19 during exercise. We described CPET data on athletes and physically active individuals with or without cardiorespiratory persistent symptoms.

Methods

Participants' assessment included medical history and physical examination, cardiac troponin T, resting electrocardiogram, spirometry and CPET. Persistent symptoms were defined as fatigue, dyspnea, chest pain, dizziness, tachycardia, and exertional intolerance persisting >2 months after COVID-19 diagnosis.

Results

A total of 46 participants were included; sixteen (34.8%) were asymptomatic and thirty participants (65.2%) reported persistent symptoms, with fatigue and dyspnea being the most reported ones (43.5 and 28.1%). There were a higher proportion of symptomatic participants with abnormal data for slope of pulmonary ventilation to carbon dioxide production (VE/VCO2 slope; p<0.001), end-tidal carbon dioxide pressure at rest (PETCO2 rest; p=0.007), PETCO2 max (p=0.009), and dysfunctional breathing (p=0.023) vs. asymptomatic ones. Rates of abnormalities in other CPET variables were comparable between asymptomatic and symptomatic participants. When assessing only elite and highly trained athletes, differences in the rate of abnormal findings between asymptomatic and symptomatic participants were no longer statistically significant, except for expiratory air flow-to-percent of tidal volume ratio (EFL/VT) (more frequent among asymptomatic participants) and dysfunctional breathing (p=0.008).

Discussion

A considerable proportion of consecutive athletes and physically active individuals presented with abnormalities on CPET after COVID-19, even those who had had no persistent cardiorespiratory symptomatology. However, the lack of control parameters (e.g., pre-infection data) or reference values for athletic populations preclude stablishing the causality between COVID-19 infection and CPET abnormalities as well as the clinical significance of these findings.

Short and Long-Term Cardiovascular Sequelae after SARS-CoV-2 Infection: A Narrative Review Focusing on Athletes

Cardiovascular (CV) involvement after severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection was found to be frequent among the general population, especially in the pre-vaccination era, and particularly for hospitalized patients or those who experienced a more severe course of the disease. The spectrum of CV disease varies; however, acute myocarditis is particularly fearsome for the athletic population due to the possible associated risk of malignant arrhythmias during training. Alarming percentages of CV injuries, even in young and healthy athletes with a benign course of the disease, arose from a few initial studies limited to case series. Subsequent single-center studies and larger observational registries reported a lower prevalence of SARS-CoV2 CV involvement in athletes. Studies showing the occurrence of CV adverse events during follow-up periods are now available. The objective of our narrative review is to provide an updated summary of the literature on CV involvement after coronavirus disease 2019, both in the early post-infection period and over a longer period of time, with a focus on athletic populations.

Cardiac Arrhythmias in Post-COVID Syndrome: Prevalence, Pathology, Diagnosis, and Treatment

An increase in post-COVID patients with late sequelae of acute COVID-19 infection is emerging as an ongoing challenge for physicians and healthcare professionals. Since the beginning of the pandemic, it has rapidly become evident that the acute infection is not limited to the respiratory tract but that several organs, including the cardiovascular system, can be affected. Moreover, in a significant proportion of patients (ranging from about 10 to up to 50%) with former COVID-19, cardiopulmonary symptoms such as dyspnea, palpitations, restricted physical capacity, and cardiac arrhythmias can persist weeks and months after the acute SARS-CoV-2 infection. The spectrum of COVID-19-associated arrhythmias is rather wide, most likely due to various pathomechanisms. In this article, the prevalence of cardiac arrhythmias and underlying pathologies are reviewed, including direct myocardial injury and abnormal consequences with an impact on cardiac electric instability. The hyperinflammatory reaction of the host immune system is specifically considered. Moreover, several distinct rhythm disorders occurring in post-COVID patients are discussed with regard to their clinical management.

Measuring objective fatigability and autonomic dysfunction in clinical populations: How and why?

Fatigue is a major symptom in many diseases, often among the most common and severe ones and may last for an extremely long period. Chronic fatigue impacts quality of life, reduces the capacity to perform activities of daily living, and has socioeconomical consequences such as impairing return to work. Despite the high prevalence and deleterious consequences of fatigue, little is known about its etiology. Numerous causes have been proposed to explain chronic fatigue. They encompass psychosocial and behavioral aspects (e.g., sleep disorders) and biological (e.g., inflammation), hematological (e.g., anemia) as well as physiological origins. Among the potential causes of chronic fatigue is the role of altered acute fatigue resistance, i.e. an increased fatigability for a given exercise, that is related to physical deconditioning. For instance, we and others have recently evidenced that relationships between chronic fatigue and increased objective fatigability, defined as an abnormal deterioration of functional capacity (maximal force or power), provided objective fatigability is appropriately measured. Indeed, in most studies in the field of chronic diseases, objective fatigability is measured during single-joint, isometric exercises. While those studies are valuable from a fundamental science point of view, they do not allow to test the patients in ecological situations when the purpose is to search for a link with chronic fatigue. As a complementary measure to the evaluation of neuromuscular function (i.e., fatigability), studying the dysfunction of the autonomic nervous system (ANS) is also of great interest in the context of fatigue. The challenge of evaluating objective fatigability and ANS dysfunction appropriately (i.e.,. how?) will be discussed in the first part of the present article. New tools recently developed to measure objective fatigability and muscle function will be presented. In the second part of the paper, we will discuss the interest of measuring objective fatigability and ANS (i.e. why?). Despite the beneficial effects of physical activity in attenuating chronic fatigue have been demonstrated, a better evaluation of fatigue etiology will allow to personalize the training intervention. We believe this is key in order to account for the complex, multifactorial nature of chronic fatigue.

Low Cardiorespiratory Fitness Post-COVID-19: A Narrative Review

Patients recovering from COVID-19 often report symptoms of exhaustion, fatigue and dyspnoea and present with exercise intolerance persisting for months post-infection. Numerous studies investigated these sequelae and their possible underlying mechanisms using cardiopulmonary exercise testing. We aimed to provide an in-depth discussion as well as an overview of the contribution of selected organ systems to exercise intolerance based on the Wasserman gears. The gears represent the pulmonary system, cardiovascular system, and periphery/musculature and mitochondria. Thirty-two studies that examined adult patients post-COVID-19 via cardiopulmonary exercise testing were included. In 22 of 26 studies reporting cardiorespiratory fitness (herein defined as peak oxygen uptake-VO2peak), VO2peak was < 90% of predicted value in patients. VO2peak was notably below normal even in the long-term. Given the available evidence, the contribution of respiratory function to low VO2peak seems to be only minor except for lung diffusion capacity. The prevalence of low lung diffusion capacity was high in the included studies. The cardiovascular system might contribute to low VO2peak via subnormal cardiac output due to chronotropic incompetence and reduced stroke volume, especially in the first months post-infection. Chronotropic incompetence was similarly present in the moderate- and long-term follow-up. However, contrary findings exist. Peripheral factors such as muscle mass, strength and perfusion, mitochondrial function, or arteriovenous oxygen difference may also contribute to low VO2peak. More data are required, however. The findings of this review do not support deconditioning as the primary mechanism of low VO2peak post-COVID-19. Post-COVID-19 sequelae are multifaceted and require individual diagnosis and treatment.

Low prevalence of cardiac abnormalities in competitive athletes at return-to-play after COVID-19

OBJECTIVE

to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes at return-to-play (RTP) evaluation, following the recommended Italian protocol including cardiopulmonary exercise test (CPET) and 24-Hour Holter monitoring.

DESIGN AND METHODS

this is a single centre observational, cross-sectional study. Since October 2020, all competitive athletes (age ≥ 14 years) evaluated in our Institute after COVID-19, prior RTP were enrolled. The protocol dictated by the Italian governing bodies included: 12‑lead ECG, blood test, CPET, 24-h ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication.

RESULTS

219 consecutive athletes were examined (59% male), age 23 years (IQR 19-27), 21% asymptomatic, 77% mildly symptomatic, 2% with previous pneumonia. The evaluation was performed after a median of 10 (6-17) days from negative SARS-CoV-2 swab. All athletes showed a good exercise capacity at CPET without cardiovascular and respiratory limitations. Uncommon premature ventricular contractions (PVCs) were found in 9.5% (n = 21) at CPET/Holter ECG monitoring. Two athletes (0.9%) were diagnosed with acute myocarditis (by CMR) and another one with new pericardial effusion. All the three athletes were temporally restricted from sport participation.

CONCLUSIONS

Myocarditis in competitive athletes screened after COVID-19 resolution was detected in a low minority of the cases (0.9%). However, a non-negligible prevalence of uncommon PVCs (9%) was observed, either at CPET and/or Holter ECG monitoring, including all athletes with COVID-19 related cardiovascular abnormalities.

Post-Acute Sequelae of COVID-19: The Potential Role of Exercise Therapy in Treating Patients and Athletes Returning to Play

Post-acute sequelae of coronavirus disease 19 (COVID-19) (PASC) describe a wide range of symptoms and signs involving multiple organ systems occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, representing a growing health problem also in the world of sport and the athletic population. Patients with PASC have new, returning, or persisting symptoms four or more weeks after the infection. Among the most frequent symptoms, patients complain of fatigue, dyspnea, exercise intolerance, and reduced functional capacity that interfere with everyday life activity. The role of exercise programs in PASC patients will be identified, and upcoming studies will establish the magnitude of their benefits. However, the benefits of exercise to counteract these symptoms are well known, and an improvement in cardiopulmonary fitness, functional status, deconditioning, and quality of life can be obtained in these patients, as demonstrated in similar settings. Based on this background, this review aims to summarise the current evidence about the PASC syndrome and the benefit of exercise in these patients and to provide a practical guide for the exercise prescription in PASC patients to help them to resume their functional status, exercise tolerance, prior activity levels, and quality of life, also considering the athletic population and their return to play and sports competitions.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

After SARS-CoV-2 infection, strict recommendations for return-to-sport were published. However, data are insufficient about the long-term effects on athletic performance. After suffering SARS-CoV-2 infection, and returning to maximal-intensity trainings, control examinations were performed with vita-maxima cardiopulmonary exercise testing (CPET). From various sports, 165 asymptomatic elite athletes (male: 122, age: 20y (IQR: 17-24y), training:16 h/w (IQR: 12-20 h/w), follow-up:93.5 days (IQR: 66.8-130.0 days) were examined. During CPET examinations, athletes achieved 94.7 ± 4.3% of maximal heart rate, 50.9 ± 6.0 mL/kg/min maximal oxygen uptake (V̇O2max), and 143.7 ± 30.4L/min maximal ventilation. Exercise induced arrhythmias (n = 7), significant horizontal/descending ST-depression (n = 3), ischemic heart disease (n = 1), hypertension (n = 7), slightly elevated pulmonary pressure (n = 2), and training-related hs-Troponin-T increase (n = 1) were revealed. Self-controlled CPET comparisons were performed in 62 athletes: due to intensive re-building training, exercise time, V̇O2max and ventilation increased compared to pre-COVID-19 results. However, exercise capacity decreased in 6 athletes. Further 18 athletes with ongoing minor long post-COVID symptoms, pathological ECG (ischemic ST-T changes, and arrhythmias) or laboratory findings (hsTroponin-T elevation) were controlled. Previous SARS-CoV-2-related myocarditis (n = 1), ischaemic heart disease (n = 1), anomalous coronary artery origin (n = 1), significant ventricular (n = 2) or atrial (n = 1) arrhythmias were diagnosed. Three months after SARS-CoV-2 infection, most of the athletes had satisfactory fitness levels. Some cases with SARS-CoV-2 related or not related pathologies requiring further examinations, treatment, or follow-up were revealed.

The COVID-19 in athletes (COVA) study: a national study on cardio-pulmonary involvement of SARS-CoV-2 infection among elite athletes

Background

COVID-19 can cause cardiopulmonary involvement. Physical activity and cardiac complications can worsen prognosis, while pulmonary complications can reduce performance.

Aims

To determine the prevalence and clinical implications of SARS-CoV-2 cardiopulmonary involvement in elite athletes.

Methods

An observational study between 1 July 2020 and 30 June 2021 with the assessment of coronary biomarkers, electrocardiogram, echocardiography, Holter-monitoring, spirometry, and chest X-ray in Danish elite athletes showed that PCR-tested positive for SARS-CoV-2. The cohort consisted of male football players screened weekly (cohort I) and elite athletes on an international level only tested if they had symptoms, were near-contact, or participated in international competitions (cohort II). All athletes were categorized into two groups based on symptoms and duration of COVID-19: Group 1 had no cardiopulmonary symptoms and duration ≤7 days, and; Group 2 had cardiopulmonary symptoms or disease duration >7 days.

Results

In total 121 athletes who tested positive for SARS-CoV-2 were investigated. Cardiac involvement was identified in 2/121 (2%) and pulmonary involvement in 15/121 (12%) participants. In group 1, 87 (72%), no athletes presented with signs of cardiac involvement, and 8 (7%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. In group 2, 34 (28%), two had myocarditis (6%), and 8 (24%) were diagnosed with radiological COVID-19-related findings or obstructive lung function.

Conclusions

These clinically-driven data show no signs of cardiac involvement among athletes who tested positive for SARS-CoV-2 infection without cardiopulmonary symptoms and duration <7 days. Athletes with cardiopulmonary symptoms or prolonged duration of COVID-19 display, exercise-limiting cardiopulmonary involvement.

Psychological and Mental Sequelae in Elite Athletes with Previous SARS-CoV-2 Infection: A Systematic Review

During the COVID-19 pandemic, many athletes from several sporting disciplines were infected with the SARS-CoV-2. The aim of this systematic review is to summarize the current scientific evidence on the psychological sequelae and mental health of elite athletes who have been infected by the virus. The review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement; three databases were searched: PubMed, ISI Web of Knowledge, and Scopus. The initial search resulted in 2420 studies; after duplicate removal and screening by title and abstract, 41 articles were screened by full-text. A total of four eligible articles were included in the review. All included articles measured depression and anxiety in athletes who had suffered from COVID-19, while in three papers levels of stress were measured. Overall, the only two questionnaires used in more than one study were the DASS-21 and the APSQ. In our systematic review, we highlighted that mental and psychological health in elite athletes has the same importance as physical health. This statement suggests that these examinations should be introduced and performed during the competitive sports' medical examinations conducted at the start of the sporting season, which currently consists only of the examination of physical parameters. Due to lack of studies on the topic, the results of our review show that mental health in athletes with a history of SARS-CoV-2 infection is an issue that requires more investigation, considering the evidence of clinical consequences. The importance of post-infection psychological sequelae is significant in assessing possible repercussions on the athletes' sporting performance.

Incidence and Clinical Relevance of COVID-19 in a Population of Young Competitive and Elite Football Players: A Retrospective Observational Study

Background

The COVID-19 pandemic dramatically changed lifestyle worldwide, including sport. A comprehensive evaluation of the prevalence of cardiac involvement in COVID-19 is essential to finalize a safe protocol for resuming elite sport. The aim of this study is to evaluate incidence of cardiac involvement and COVID-19 impact on athletic performance.

Materials and methods

This retrospective observational study analysed the data collected from consecutive competitive athletes who performed medical-sports examinations at the J Medical Center from March 2020 to March 2021. All athletes periodically performed a molecular test using a nasopharyngeal swab to detect COVID-19 infection. Positive athletes performed laboratory (cardiac troponin T—cTnT) and instrumental (echocardiography, stress test, Holter ECG) investigations following recovery to identify any cardiac involvement. Cardiac magnetic resonance imaging (MRI) was performed in case of abnormal findings at first-level evaluation.

Results

Among 238 athletes (median age 20 years), 77 contracted COVID-19, mainly males (79%) with a median age of 16 years. Fifty-one athletes (66%) presented mild symptoms, and none required hospitalization. Evaluation for resuming sport was performed after a median of 30 days from the first positive test. Abnormal findings were obtained in 13 cases (5 athletes [6%] with elevated cTnT values; 13 athletes [17%] with arrhythmias on Holter ECG and/or during stress test; 2 athletes [3%] anomalies at echocardiography). Cardiac MRI discovered abnormalities in 9 cases, but none of these was clearly related to COVID-19 and none fulfilled acute myocarditis criteria. No negative impact on athletic performance was observed, and none of the athletes developed persistent COVID-related symptoms.

Conclusions

Our registry confirms the predominantly self-limiting illness in young athlete population. The incidence of clear COVID-19-related structural myocardial injury was very low, but transient exertional ventricular arrhythmias or pericardial effusion was observed without significant impact on athletic performance. Implemented screening for return to activity is likely reasonable only in moderate-to-severe symptomatic athletes.

Cardiovascular Concerns from COVID-19 in Pilots

BACKGROUND: Cardiovascular disease, now complicated by the COVID-19 pandemic, remains a leading cause of death and risk for sudden incapacitation for pilots during flight. The capacity for aeromedically significant cardiovascular sequelae with potentially imperceptible clinical symptoms elicits concern both during and following resolution of acute COVID-19 in pilots.OBJECTIVE: We summarize the current state of knowledge regarding COVID-19 cardiovascular implications as applied to the aviation environment to better understand their significance toward flight safety and application toward a focused cardiovascular screening protocol following recovery from infection.METHODS: A narrative review of the cardiovascular implications of COVID-19 infection was performed using the PubMed literature search engine and existing organizational guidelines. In addition, to established medical aviation benchmarks, surrogate populations examined included high performance athletes (as a correlate for high G-forces), and scuba divers (as an environmental work analog). Conditions of primary concern included myocardial injury, proarrhythmic substrates, risk of sudden death, myopericarditis, pulse orthostatic lability in response to vigorous activity, cardiovagal dysfunction, and thromboembolic disease.LITERATURE REVIEW: Cardiovascular screening guideline recommendations post-infection recovery are suggested based on profile stratification: airperson flight class, tactical military, and aerobatic pilots. This provides an approach to inform aeromedical decision making.CONCLUSION: Aviation medical examiners should remain cognizant of the clinically apparent and occult manifestations of cardiovascular dysfunction associated with COVID-19 infection when applying return-to-work screening guidelines. This will ensure high flight safety standards are maintained and sudden incapacitation risk mitigated during and following the ongoing pandemic.Elkhatib W, Herrigel D, Harrison M, Flipse T, Speicher L. Cardiovascular concerns from COVID-19 in pilots. Aerosp Med Hum Perform. 2022; 93(12):855-865.

Repeated cardiopulmonary performance measurements in young competitive handball players with and without SARS-CoV-2 infection

BACKGROUND

The SARS-CoV-2 virus and its long-term consequences in adolescents have a global impact on upcoming medical issues. The aim of this study was to investigate the effects of a SARS-CoV-2 infection on cardiorespiratory parameters in young athletes.

METHODS

In a cohort study involving repeated measurements during a six-month period, cardiorespiratory parameters were assessed in infected (SCoV) and non-infected (noSCoV) athletes. We evaluated handball players (17.2 ± 1.0 years) via performance diagnostics and a specific examination after a SARS-CoV-2 infection or without.

RESULTS

We observed no significant differences between the two groups at the first visit. But between the first and second visit, the SCoV group's maximum power output was significantly lower than the noSCoV group's (- 48.3 ± 12.5; p ≤ 0.01 vs. - 15.0 ± 26.0 W; p = 0.09). At the second visit, lung diffusion capacity (DL_CO/V_A, %predicted) did not differ between groups (111.6 ± 11.5 vs. 116.1 ± 11.8%; p = 0.45). HR during comparative stress showed no group differences. The SCoV group's mean oxygen uptake during incremental exercise was lower (Two-way-ANOVA: 1912 vs. 2106 ml; p ≤ 0.01; mean difference: - 194 ml; 95% CI - 317 to - 71); we also noted a significantly lower stroke volume course during exercise (Two-way-ANAOVA: 147.5 vs. 169.5 ml; mean difference: - 22 ml; p ≤ 0.01; 95% CI - 34.2 to - 9.9). The probability of premature ventricular complexes after a SARS-CoV-2 infection yielded an odds ratio of 1.6 (95% CI 0.24-10.81).

CONCLUSIONS

The physical performance of young athletes infected with SARS-CoV-2 was impaired. This decreased performance is probably due to cardiac and/or peripheral deconditioning. Studies with larger cohorts are needed to make more profound conclusions.

Coronavirus disease 2019 and the young heart: prevention, treatment, and return to play

PURPOSE OF REVIEW

COVID-19-related guidance has changed dramatically since the onset of the pandemic. Awareness of data regarding prevention of disease, the cardiac manifestations and treatment of acute COVID-19 and multisystem inflammatory syndrome in children, and return to physical activity following an infection allows for appropriate adjustment of current care models and guides future study.

RECENT FINDINGS

Severe acute respiratory syndrome coronavirus 2 transmission can be reduced using various mitigation strategies, though their effectiveness differs based on viral prevalence. The risk of severe disease during acute COVID-19 infection is low in children and adolescents, though specific risk factors have been identified. COVID-19 vaccination significantly decreases the risk of severe disease and poor outcomes. Regular physical activity positively affects well being and has been a focus of recent guidance regarding well tolerated return to activities following an infection.

SUMMARY

The use of strategies to reduce viral transmission will depend on individuals' and communities' risk tolerance and on current viral prevalence. COVID-19 vaccination should be encouraged, particularly in patients with identified risk factors. Allowing children and adolescents to safely participate in physical and other activities should continue to be a focus of our clinical and research efforts given their myriad benefits in this population.

Cardiac screening prior to return to play after SARS-CoV-2 infection: focus on the child and adolescent athlete: A Clinical Consensus Statement of the Task Force for Childhood Health of the European Association of Preventive Cardiology

Cardiac sequelae after COVID-19 have been described in athletes, prompting the need to establish a return-to-play (RTP) protocol to guarantee a safe return to sports practice. Sports participation is strongly associated with multiple short- and long-term health benefits in children and adolescents and plays a crucial role in counteracting the psychological and physical effects of the current pandemic. Therefore, RTP protocols should be balanced to promote safe sports practice, particularly after an asymptomatic SARS-CoV-2 infection that represents the common manifestation in children. The present consensus document aims to summarize the current evidence on the cardiac sequelae of COVID-19 in children and young athletes, providing key messages for conducting the RTP protocol in paediatric athletes to promote a safe sports practice during the COVID-19 era.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 1: acute respiratory infections

Acute illnesses affecting the respiratory tract are common and form a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. Acute respiratory illness (ARill) can broadly be classified as non-infective ARill and acute respiratory infections (ARinf). The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to ARinf in athletes. The International Olympic Committee (IOC) Medical and Scientific Commission appointed an international consensus group to review ARill (non-infective ARill and ARinf) in athletes. Six subgroups of the IOC Consensus group were initially established to review the following key areas of ARill in athletes: (1) epidemiology/risk factors for ARill, (2) ARinf, (3) non-infective ARill including ARill due to environmental exposure, (4) acute asthma and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport and (6) acute nasal/vocal cord dysfunction presenting as ARill. Several systematic and narrative reviews were conducted by IOC consensus subgroups, and these then formed the basis of sections in the consensus documents. Drafting and internal review of sections were allocated to 'core' members of the consensus group, and an advanced draft of the consensus document was discussed during a meeting of the main consensus core group in Lausanne, Switzerland on 11 to 12 October 2021. Final edits were completed after the meeting. This consensus document (part 1) focusses on ARinf, which accounts for the majority of ARill in athletes. The first section of this consensus proposes a set of definitions and classifications of ARinf in athletes to standardise future data collection and reporting. The remainder of the consensus paper examines a wide range of clinical considerations related to ARinf in athletes: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations, risks of infection during exercise, effects of infection on exercise/sports performance and return-to-sport guidelines.

Systematic Cardiovascular Screening in Olympic Athletes before and after SARS-CoV-2 Infection

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in athletes. The aim of this study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program. Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior to RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-h ECG monitoring, and spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation. Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, and 4% had pneumonia. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes; however, only 6% (n = 3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR. Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority, and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in the presence of symptoms and elevated biomarkers). Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears unjustified.

Acute and post-acute COVID-19 presentations in athletes: a systematic review and meta-analysis

OBJECTIVE

To describe acute/postacute COVID-19 presentations in athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The search was conducted in four databases (MEDLINE, EMBASE, SCOPUS, SPORTDiscus) and restricted to studies published from 2019 to 6 January 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were required to (1) include professional, amateur or collegiate/university athletes with COVID-19; (2) present data on acute/postacute COVID-19 symptoms and (3) have an observational design. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools.

RESULTS

43 studies with 11 518 athletes were included. For acute presentation, the pooled event rates for asymptomatic and severe COVID-19 were 25.5% (95% CI: 21.1% to 30.5%) and 1.3% (95% CI: 0.7% to 2.3%), respectively. For postacute presentations, the pooled estimate of persistent symptoms was 8.3% (95% CI: 3.8% to 17.0%). Pooled estimate for myocardial involvement was 5.0% (95% CI: 2.5% to 9.8%) in athletes undergoing any cardiac testing, and 2.5% (95% CI: 1.0% to 5.8%) in athletes undergoing MRI, although clinical symptoms were not characterised. None of the studies with a control group (eg, non-infected athletes) could confirm a causal relationship between COVID-19 and myocardial involvement.

CONCLUSION

This broad characterisation of COVID-19 presentations in athletes indicates that ~94% exhibited mild or no acute symptoms. The available evidence did not confirm a causal relationship between COVID-19 and myocardial involvement. A small proportion of athletes experienced persistent symptoms while recovering from infection, which were mostly mild in nature, but could affect return-to-play decisions and timing.

Diagnostic evaluation and cardiopulmonary exercise test findings in young athletes with persistent symptoms following COVID-19

OBJECTIVES

Persistent or late-onset cardiopulmonary symptoms following COVID-19 may occur in athletes despite a benign initial course. We examined the yield of cardiac evaluation, including cardiopulmonary exercise testing (CPET), in athletes with cardiopulmonary symptoms after COVID-19, compared CPETs in these athletes and those without COVID-19 and evaluated longitudinal changes in CPET with improvement in symptoms.

METHODS

This prospective cohort study evaluated young (18-35 years old) athletes referred for cardiopulmonary symptoms that were present>28 days from COVID-19 diagnosis. CPET findings in post-COVID athletes were compared with a matched reference group of healthy athletes without COVID-19. Post-COVID athletes underwent repeat CPET between 3 and 6 months after initial evaluation.

RESULTS

Twenty-one consecutive post-COVID athletes with cardiopulmonary symptoms (21.9±3.9 years old, 43% female) were evaluated 3.0±2.1 months after diagnosis. No athlete had active inflammatory heart disease. CPET reproduced presenting symptoms in 86%. Compared with reference athletes (n=42), there was similar peak VO2 but a higher prevalence of abnormal spirometry (42%) and low breathing reserve (42%). Thirteen athletes (62%) completed longitudinal follow-up (4.8±1.9 months). The majority (69%) had reduction in cardiopulmonary symptoms, accompanied by improvement in peak VO2 and oxygen pulse, and reduction in resting and peak heart rate (all p<0.05).

CONCLUSION

Despite a high burden of cardiopulmonary symptoms after COVID-19, no athlete had active inflammatory heart disease. CPET was clinically useful to reproduce symptoms with either normal testing or identification of abnormal spirometry as a potential therapeutic target. Improvement in post-COVID symptoms was accompanied by improvements in CPET parameters.

Predictors of Submaximal Exercise Test Attainment in Adults Reporting Long COVID Symptoms

Adults with long COVID often report intolerance to exercise. Cardiopulmonary exercise testing (CPET) has been used in many settings to measure exercise ability but has been conducted in a few long COVID cohorts. We conducted CPET in a sample of adults reporting long COVID symptoms using a submaximal cycle ergometer protocol. We studied pre-exercise predictors of achieving 85% of the age-predicted maximum heart rate (85%HRmax) using logistic regression. Eighty participants were included (mean age 46 years, range 25−78, 71% women). Forty participants (50%) did not reach 85%HRmax. On average, non-achievers reached 84% of their predicted 85%HRmax. No adverse events occurred. Participants who did not achieve 85%HRmax were older (p < 0.001), had more recent COVID-19 illness (p = 0.012) with higher frequency of hospitalization (p = 0.025), and had been more affected by dizziness (p = 0.041) and joint pain (p = 0.028). In the logistic regression model including age, body mass index, time since COVID-19, COVID-19-related hospitalization, dizziness, joint pain, pre-existing cardiopulmonary disease, and use of beta blockers, independent predictors of achieving 85%HRmax were younger age (p = 0.001) and longer time since COVID-19 (p = 0.008). Our cross-sectional findings suggest that exercise tolerance in adults with long COVID has potential to improve over time. Longitudinal research should assess the extent to which this may occur and its mechanisms. ClinicalTrials.gov identifier: NCT05027724 (TROPIC Study).

Cardiovascular complications and outcomes among athletes with COVID-19 disease: a systematic review

Background

Current evidence still emerging regarding the risk of cardiovascular (CV) sequel associated with coronavirus disease 2019 (COVID-19) infection, and considerable replicated studies are needed to ensure safe return-to-play. Therefore, we aimed in this systematic review to measure the prevalence of CV complications suffered by COVID-19 athletic patients, explore the outcomes, optimal approaches to diagnoses, and safe return-to-play considerations.

Methods

A systematic search on post COVID-19 infection quantitative studies among athletes was conducted following MeSH terms in Medline, Cochrane Library, Ovid, Embase and Scopus (through 15 January 2022). We included peer-reviewed studies reported athletes’ CV complications and the outcomes post COVID-19 infection. Editorials, letters, commentaries, and clinical guidelines, as well as duplicate studies were excluded. Studies involving non-athletic patients were also excluded. Quality assessment was performed using Newcastle–Ottawa Scale.

Results

We included 15 eligible articles with a total of 6229 athletes, of whom 1023 were elite or professional athletes. The prevalence of myocarditis ranged between 0.4% and 15.4%, pericarditis 0.06% and 2.2%, and pericardial effusion between 0.27% and 58%. Five studies reported elevated troponin levels (0.9-6.9%).

Conclusions

This study provides a low prevalence of CV complications secondary to COVID-19 infection in short-term follow-up. Early recognition and continuous assessment of cardiac abnormality in competitive athletes are imperative to prevent cardiac complications. Establishing a stepwise evaluation approach is critical with an emphasis on imaging techniques for proper diagnosis and risk assessment for a safe return to play.

Myocarditis in Athletes Recovering from COVID-19: A Systematic Review and Meta-Analysis

Background: To assess the event rates of myocarditis detected by Cardiac Magnetic Resonance (CMR) in athletes who recovered from COVID-19. Methods: A systematic literature search was performed to identify studies reporting abnormal CMR findings in athletes who recovered from COVID-19. Secondary analyses were performed considering increased serum high sensitivity troponin (hs-Tn) levels and electrocardiographic (ECG) and echocardiographic (ECHO) abnormalities. Results: In total, 7988 athletes from 15 studies were included in the analysis. The pooled event rate of myocarditis was 1% (CI 1–2%), reaching 4% in the sub-group analysis. In addition, heterogeneity was observed (I2 43.8%). The pooled event rates of elevated serum hs-Tn levels, abnormal ECG and ECHO findings were 2% (CI 1–5%), 3% (CI 1–10%) and 2% (CI 1–6%), respectively. ECG, ECHO and serum hs-Tn level abnormalities did not show any correlation with myocarditis. Conclusions: The prevalence of COVID-19-related myocarditis in the athletic population ranges from 1 to 4%. Even if the event rate is quite low, current screening protocols are helpful tools for a safe return to play to properly address CMR studies. Trial registration: the study protocol was registered in the PROSPERO database (registration number: CRD42022300819).

Case Report: Two Case Reports of Acute Myopericarditis After mRNA COVID-19 Vaccine

Background

Cases of myocarditis and myopericarditis after mRNA COVID-19 vaccines have been reported, especially after the second dose and in young males. Their course is generally benign, with symptoms onset after 24-72 h from the dose.

Case Summary

We report two cases of myopericarditis after the second dose of the mRNA-1273 COVID-19 vaccine in two young males. Both the patients were administered the mRNA-1273 COVID-19 vaccine from the same batch on the same day and experienced fever on the same day of the vaccine, and symptoms consisted of myopericarditis 3 days after the dose.

Discussion

Myopericarditis is usually considered an uncommon adverse reaction after various vaccinations, reported also after the mRNA COVID-19 vaccine. Several explanations have been proposed, including an abnormal activation of the immune system leading to a pro-inflammatory cascade responsible for myocarditis development. Both patients experienced the same temporal onset as well as the same symptoms, it is also useful to underscore that both vaccines belonged to the same batch of vaccines. However, despite these cases, vaccination against COVID-19 far outweighs the risk linked to COVID-19 infection and remains the best option to overcome this disease.

The mechanism underlying extrapulmonary complications of the coronavirus disease 2019 and its therapeutic implication

The coronavirus disease 2019 (COVID-19) is a highly transmissible disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that poses a major threat to global public health. Although COVID-19 primarily affects the respiratory system, causing severe pneumonia and acute respiratory distress syndrome in severe cases, it can also result in multiple extrapulmonary complications. The pathogenesis of extrapulmonary damage in patients with COVID-19 is probably multifactorial, involving both the direct effects of SARS-CoV-2 and the indirect mechanisms associated with the host inflammatory response. Recognition of features and pathogenesis of extrapulmonary complications has clinical implications for identifying disease progression and designing therapeutic strategies. This review provides an overview of the extrapulmonary complications of COVID-19 from immunological and pathophysiologic perspectives and focuses on the pathogenesis and potential therapeutic targets for the management of COVID-19.

Return to Play after SARS-CoV-2 Infection in Competitive Athletes of Distinct Sport Disciplines in Italy: A FMSI (Italian Federation of Sports Medicine) Study

Background: SARS-CoV-2 can lead to several systemic complications, including myocardial injuries; these might be worsened by heavy physical activity. The optimal approach to cardiac risk stratification following SARS-CoV-2 infection in athletes for a safe return to play (RTP) still needs defining. The aim of this study was to assess the prevalence of abnormal RTP test results, according to the protocol of Italian Federation of Sport Medicine (FMSI), which was endorsed by the Italian Ministry of Health, potentially representing COVID-19-associated cardiac injuries. Methods: This was a prospective, multicenter, observational study. All consecutive competitive athletes who underwent COVID-19 RTP testing protocol from 1 May to 31 July 2021, across 60 Italian Centers of Sports Medicine, were enrolled in the study. Athletes were tested at least 30 days after negativization of the nasopharyngeal swab (or immediately after negativization in professional athletes or Probable Olympians). A 12-lead electrocardiography at rest and during maximal incremental exercise test with continuous O₂ saturation monitoring and an echocardiographic examination were part of the protocol. In athletes with “moderate” disease (NHI classification), 24 h ECG monitoring (to be performed on a training day) and Magnetic Resonance Imaging (MRI) were also performed. Results: A total of 4143 athletes (67.8% males and 32.2% females) (53% > 18 years, 20% 18–35 years and 16% > 35 years), from more than 40 different sport disciplines, were included in the study. The mean age was 22.5 ± 13.3 years, with ages ranging from 8 to 80 years. Of these athletes, 52.3% were asymptomatic, 46.4% manifested mild symptoms, 1.1% and 0.14% had moderate or severe symptoms, respectively, while critical illness was evident in one athlete. Abnormal echocardiographic findings were detected in 80 cases (1.9%), and pericarditis in 7 cases (0.2%); all were from mildly symptomatic athletes. Arrhythmic events were recorded in 239 athletes, with 224 (5.4%) in the exercise test and 15 (0.4%) during 24 h ECG monitoring. Ventricular arrhythmias were observed in 101 (2.4%) athletes from the total population (mostly isolated or couples of premature ventricular beats): 91 in the exercise test and 10 during 24 h ECG monitoring. Cardiac magnetic resonance was performed in 34 athletes; the presence of myocarditis was confirmed in 5 athletes (0.12% of the total population, 14.7% of athletes in which MRI was performed). Conclusions: According to our results, cardiac complications from SARS-CoV-2 in asymptomatic or mildly symptomatic competitive athletes are rare, and an RTP assessment based on symptoms and ECG-monitored exercise test would ensure a safe RTP in these athletes.

COVID-19 in German Competitive Sports: Protocol for a Prospective Multicenter Cohort Study (CoSmo-S)

Objective: It is unclear whether and to what extent COVID-19 infection poses health risks and a chronic impairment of performance in athletes. Identification of individual health risk is an important decision-making basis for managing the pandemic risk of infection with SARS-CoV-2 in sports and return to play (RTP).

Methods: This study aims 1) to analyze the longitudinal rate of seroprevalence of SARS-CoV-2 in German athletes, 2) to assess health-related consequences in athletes infected with SARS-CoV-2, and 3) to reveal effects of the COVID-19 pandemic in general and of a cleared SARS-CoV-2 infection on exercise performance. CoSmo-S is a prospective observational multicenter study establishing two cohorts: 1) athletes diagnosed positive for COVID-19 (cohort 1) and 2) federal squad athletes who perform their annual sports medical preparticipation screening (cohort 2). Comprehensive diagnostics including physical examination, laboratory blood analyses and blood biobanking, resting and exercise electrocardiogram (ECG), echocardiography, spirometry and exercise testing added by questionnaires are conducted at baseline and follow-up.

Results and Conclusion: We expect that the results obtained, will allow us to formulate recommendations regarding RTP on a more evidence-based level.

Cardiovascular involvement among collegiate athletes following COVID-19 infection

BACKGROUND

Recent studies suggest that the prevalence of cardiac involvement in young competitive athletes with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears to be low.

AIM

This study aimed to determine the prevalence of cardiovascular involvement in young competitive athletes.

METHODS

In this single-center retrospective cohort study from one Division I university; we assessed the prevalence of cardiovascular involvement among collegiate athletes who tested positive for SARS-CoV-2 by polymerase chain reaction testing. Data were collected from June 25, 2020, to May 15, 2021. The primary outcome was the prevalence of cardiac involvement based on a comparison of pre- and post-infection electrocardiogram (ECGs). The secondary outcome was to evaluate for any association between ethnicity and the presence or absence of symptoms.

RESULTS

Among 99 athletes who tested positive for the SARS-CoV-2 virus (mean age 19.9 years [standard deviation 1.7 years]; 31% female), baseline ECG changes suggestive of cardiovascular involvement post-infection were detected in two athletes (2/99; 2%). There was a statistically significant association between ethnicity and the presence or absence of symptoms, χ ² (3, n = 99) = 10.61, P = 0.01.

CONCLUSIONS

The prevalence of cardiovascular involvement among collegiate athletes following SARS-CoV-2 infection in this cohort is low. Afro-American and Caucasian athletes are more likely to experience symptoms following SARS-CoV-2 infection in comparison to Hispanic and Pacific Islander athletes; however, there is no association between ethnicity and symptom severity.

RELEVANCE FOR PATIENTS

These data add to the growing body of the literature and agree with larger cohorts that the risk of cardiac involvement post-infection appears to be low among elite athletic and semi-professional athletic populations.

SARS-CoV-2 infection and return to play in junior competitive athletes: is systematic cardiac screening needed?

BACKGROUND

SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents who are less susceptible to adverse clinical outcomes and are often asymptomatic.

OBJECTIVES

We conducted this prospective multicentre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return to play.

METHODS

Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting ECG, echocardiogram and exercise ECG testing. Further investigations were performed in cases of abnormal findings.

RESULTS

A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%) and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation was found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return to play was achieved after complete clinical resolution.

CONCLUSIONS

The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes.

Acute respiratory illness and return to sport: a systematic review and meta-analysis by a subgroup of the IOC consensus on 'acute respiratory illness in the athlete'

OBJECTIVE

To determine the days until return to sport (RTS) after acute respiratory illness (ARill), frequency of time loss after ARill resulting in >1 day lost from training/competition, and symptom duration (days) of ARill in athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EBSCOhost, Web of Science, January 1990-July 2020.

ELIGIBILITY CRITERIA

Original research articles published in English on athletes/military recruits (15-65 years) with symptoms/diagnosis of an ARill and reporting any of the following: days until RTS after ARill, frequency (%) of time loss >1 day after ARill or symptom duration (days) of ARill.

RESULTS

767 articles were identified; 54 were included (n=31 065 athletes). 4 studies reported days until RTS (range: 0-8.5 days). Frequency (%) of time loss >1 day after ARill was 20.4% (95% CI 15.3% to 25.4%). The mean symptom duration for all ARill was 7.1 days (95% CI 6.2 to 8.0). Results were similar between subgroups: pathological classification (acute respiratory infection (ARinf) vs undiagnosed ARill), anatomical classification (upper vs general ARill) or diagnostic method of ARinf (symptoms, physical examination, special investigations identifying pathogens).

CONCLUSIONS

In 80% of ARill in athletes, no days were lost from training/competition. The mean duration of ARill symptoms in athletes was 7 days. Outcomes were not influenced by pathological or anatomical classification of ARill, or in ARinf diagnosed by various methods. Current data are limited, and future studies with standardised approaches to definitions, diagnostic methods and classifications of ARill are needed to obtain detailed clinical, laboratory and specific pathogen data to inform RTS.

PROSPERO REGISTRATION NUMBER

CRD42020160479.

Cardiac abnormalities in athletes after SARS-CoV-2 infection: a systematic review

OBJECTIVES

Quantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports.

DESIGN

Systematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes.

DATA SOURCES

Combinations of key terms in Medline, Embase and Scopus (through 2 June 2021).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Inclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age <18 or >64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists.

RESULTS

In total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%-15%, pericardial effusion 0%-58% and late gadolinium enhancement (LGE) 0%-46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%-4%) versus low scores (38%-42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities.

SUMMARY/CONCLUSION

Athletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.

The Impact of COVID-19 on the Preparation for the Tokyo Olympics: A Comprehensive Performance Assessment of Top Swimmers

BACKGROUND

The Olympic preparation of athletes has been highly influenced by COVID and post-COVID syndrome. As the complex screening of athletes is essential for safe and successful sports, we aimed to repeat the 2019-year sports cardiology screening of the Olympic Swim Team before the Olympics and to compare the results of COVID and non-COVID athletes.

METHODS

Patient history, electrocardiogram, laboratory tests, body composition analysis, echocardiography, cardiopulmonary exercise test (CPET) were performed. We used time-ranking points to compare swimming performance.

RESULTS

From April 2019, we examined 46 elite swimmers (24 ± 4 years). Fourteen swimmers had COVID infection; all cases were mild. During CPET there was no difference in the performance of COVID (male: VO2 max 55 ± 4 vs. 56.5 ± 5 mL/kg/min, p = 0.53; female: VO2 max 54.6 ± 4 vs. 56 ± 5.5 mL/kg/min, p = 0.86) vs. non-COVID athletes (male VO2 max 56.7 ± 5 vs. 55.5 ± 4.5 mL/kg/min, p = 0.50; female 49.6 ± 3 vs. 50.7 ± 2.6 mL/kg/min, p = 0.47) between 2019 and 2021. When comparing the time results of the National Championships, 54.8% of the athletes showed an improvement (p = 0.75).

CONCLUSIONS

COVID infection with short-term detraining did not affect the performance of well-trained swimmers. According to our results, the COVID pandemic did not impair the effectiveness of the preparation for the Tokyo Olympics.