High Prevalence of Pericardial Involvement in College Student Athletes Recovering From COVID-19

Prevalence of Abnormal Cardiovascular Magnetic Resonance Findings in Athletes Recovered from COVID-19 Infection: A Systematic Review and Meta-Analysis

Background: Competitive sports and high-level athletic training result in a constellation of changes in the myocardium that comprise the 'athlete's heart'. With the spread of the COVID-19 pandemic, there have been concerns whether elite athletes would be at higher risk of myocardial involvement after infection with the virus. This systematic review and meta-analysis evaluated the prevalence of abnormal cardiovascular magnetic resonance (CMR) findings in elite athletes recovered from COVID-19 infection. Methods: The PubMed, Cochrane and Web of Science databases were systematically search from inception to 15 November 2023. The primary endpoint was the prevalence of abnormal cardiovascular magnetic resonance findings, including the pathological presence of late gadolinium enhancement (LGE), abnormal T1 and T2 values and pericardial enhancement, in athletes who had recovered from COVID-19 infection. Results: Out of 3890 records, 18 studies with a total of 4446 athletes were included in the meta-analysis. The pooled prevalence of pathological LGE in athletes recovered from COVID-19 was 2.0% (95% CI 0.9% to 4.4%, I2 90%). The prevalence of elevated T1 and T2 values was 1.2% (95% CI 0.4% to 3.6%, I2 87%) and 1.2% (95% CI 0.4% to 3.7%, I2 89%), respectively, and the pooled prevalence of pericardial involvement post COVID-19 infection was 1.1% (95% CI 0.5% to 2.5%, I2 85%). The prevalence of all abnormal CMR findings was much higher among those who had a clinical indication of CMR. Conclusions: Among athletes who have recently recovered from COVID-19 infection, there is a low prevalence of abnormal CMR findings. However, the prevalence is much higher among athletes with symptoms and/or abnormal initial cardiac screening. Further studies and longer follow up are needed to evaluate the clinical relevance of these findings and to ascertain if they are associated with adverse events.

Low rates of myocardial fibrosis and ventricular arrhythmias in recreational athletes after SARS-CoV-2 infection

Introduction

High rates of cardiac involvement were reported in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. This led to anxiety in the athletic population. The current study was set up to assess the prevalence of myocardial fibrosis and ventricular arrhythmias in recreational athletes with the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Methods

Consecutive adult recreational athletes (≥18 years old, ≥4 h of mixed type or endurance sports/week) underwent systematic cardiac evaluation after a prior confirmed COVID-19 infection. Evaluation included clinical history, electrocardiogram (ECG), 5-day Holter monitoring, and cardiac magnetic resonance (CMR) imaging with simultaneous measurement of high-sensitive cardiac Troponin I. Data from asymptomatic or mildly symptomatic athletes (Group 1) were compared with those with moderate to severe symptoms (Groups 2-3). Furthermore, a comparison with a historical control group of athletes without COVID-19 (Master@Heart) was made.

Results

In total, 35 athletes (18 Group 1, 10 female, 36.9 ± 2.2 years, mean 143 ± 20 days following diagnosis) were evaluated. The baseline characteristics for the Group 1 and Groups 2-3 athletes were similar. None of the athletes showed overt myocarditis on CMR based on the updated Lake Louise criteria for diagnosis of myocarditis. The prevalence of non-ischemic late gadolinium enhancement [1 (6%) Group 1 vs. 2 (12%) Groups 2-3; p = 0.603] or ventricular arrhythmias [1 Group 1 athlete showed non-sustained ventricular tachycardia (vs. 0 in Groups 2-3: p = 1.000)] were not statistically different between the groups. When the male athletes were compared with the Master@Heart athletes, again no differences regarding these criteria were found.

Conclusion

In our series of recreational athletes with prior confirmed COVID-19, we found no evidence of ongoing myocarditis, and no more detection of fibrosis or ventricular arrhythmias than in a comparable athletic pre-COVID cohort. This points to a much lower cardiac involvement of COVID-19 in athletes than originally suggested.

Long-Term Effects of COVID-19 on the Cardiopulmonary System in Adults and Children: Current Status and Questions to be Resolved by the National Institutes of Health Researching COVID to Enhance Recovery Initiative

TOPIC IMPORTANCE

Long COVID may occur in at least 10% of patients recovering from SARS-CoV-2 infection and often is associated with debilitating symptoms. Among the organ systems that might be involved in its pathogenesis, the respiratory and cardiovascular systems may be central to common symptoms seen in survivors of COVID-19, including fatigue, dyspnea, chest pain, cough, and exercise intolerance. Understand the exact symptomatology, causes, and effects of long COVID on the heart and lungs may help us to discover new therapies. To that end, the National Institutes of Health is sponsoring a national study population of diverse volunteers to support large-scale studies on the long-term effects of COVID-19.

REVIEW FINDINGS

The National Institutes of Health Researching COVID to Enhance Recovery (RECOVER) initiative currently is recruiting participants in the United States to answer critical questions about long COVID. The study comprises adult and pediatric cohorts as well as an electronic health record cohort. Based on symptoms, individuals undergo prespecified medical testing to understand whether abnormalities can be detected and are followed up longitudinally. Herein, we outline current understanding of the clinical symptoms and pathophysiologic features of long COVID with respect to the cardiopulmonary system in adults and children and then determine how the clinical, electronic health record, and autopsy cohorts of the RECOVER initiative will attempt to answer the most pressing questions surrounding the long-term effects of COVID-19.

SUMMARY

Data generated from the RECOVER initiative will provide guidance about missing gaps in our knowledge about long COVID and how they might be filled by data gathered through the RECOVER initiative.

Electrocardiography in Children Hospitalized for COVID-19 and Not Suffering from Multisystem Inflammatory Syndrome in Children (MIS-C): An Observational Study

The risk of cardiac involvement with electrophysiological abnormalities during COVID-19 infection has been reported in adults but remains poorly studied in children. Our aim was to determine the frequency of cardiac involvement and the necessity of routine cardiac evaluation in children hospitalized for COVID-19. This observational study included 127 children, with a median (IQR) age of 2 (0.83-6.0) years, who were hospitalized for COVID-19 between 1 January 2021 and 31 August 2022, 62 (48.8%) of whom were males. Each patient underwent an ECG on admission and discharge as well as a laboratory assessment. A comparison between patients with COVID-19 and healthy controls showed significantly higher HR (p < 0.0001) and lower PR values (p = 0.02) in the first group. No arrhythmias or other electrocardiographic abnormalities were detected during hospitalization. The median levels of troponin, NT-proBNP, ferritin, and D-dimer were significantly higher in children aged <2 years, but they fell within the normal range for their age. Our results indicate that a detectable cardiac involvement is very rare in children hospitalized for COVID-19 and not suffering from Multisystem Inflammatory Syndrome in Children (MIS-C) and suggest that routine electrocardiographic assessment is not mandatory in these patients in the absence of cardiac symptoms/signs.

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.

Myocardial Strain for the Differentiation of Myocardial Involvement in the Post-Acute Sequelae of COVID-19-A Multiparametric Cardiac MRI Study

Myocardial involvement was shown to be associated with an unfavorable prognosis in patients with COVID-19, which could lead to fatal outcomes as in myocardial injury-induced arrhythmias and sudden cardiac death. We hypothesized that magnetic resonance imaging (MRI) myocardial strain parameters are sensitive markers for identifying subclinical cardiac dysfunction associated with myocardial involvement in the post-acute sequelae of COVID-19 (PASC). This study evaluated 115 subjects, including 65 consecutive COVID-19 patients, using MRI for the assessment of either post-COVID-19 myocarditis or other cardiomyopathies. Subjects were categorized, based on the results of the MRI exams, as having either 'suspected' or 'excluded' myocarditis. A control group of 50 matched individuals was studied. Along with parameters of global cardiac function, the MRI images were analyzed for measurements of the myocardial T1, T2, extracellular volume (ECV), strain, and strain rate. Based on the MRI late gadolinium enhancement and T1/T2/ECV mappings, myocarditis was suspected in 7 out of 22 patients referred due to concern of myocarditis and in 9 out of 43 patients referred due to concern of cardiomyopathies. The myocardial global longitudinal, circumferential, and radial strains and strain rates in the suspected myocarditis group were significantly smaller than those in the excluded myocarditis group, which in turn were significantly smaller than those in the control group. The results showed significant correlations between the strain, strain rate, and global cardiac function parameters. In conclusion, this study emphasizes the value of multiparametric MRI for differentiating patients with myocardial involvement in the PASC based on changes in the myocardial contractility pattern and tissue structure.

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.

Cardiac magnetic resonance assessment of athletic myocardial fibrosis; Benign bystander or malignant marker?

The benefits of exercise are irrefutable with a well-established dose-dependent relationship between exercise intensity and reduction in cardiovascular disease. Differentiating the physiological adaptation to exercise, termed the "athlete's heart" from cardiomyopathies, has been advanced by the advent of more sophisticated imaging modalities such as cardiac magnetic resonance imaging (CMR). Myocardial fibrosis on CMR is a mutual finding amongst seemingly healthy endurance athletes and individuals with cardiomyopathy. As a substrate for arrhythmias, fibrosis is traditionally associated with increased cardiovascular risk. In this article, we discuss the aetiologies, distribution and potential implications of myocardial fibrosis in athletes.

Short-Term Outcomes of Cardiac Arrhythmias Among COVID-19 Patients: A Propensity Matched National Study

The risk of arrhythmia is high in patients with COVID-19. The current literature is limited in understanding the clinical impact of arrhythmias and the extent of healthcare utilization in COVID-19 patients. The Nationwide In-patient Sample Database (NIS) from 2019 to 2020 was queried to identify COVID-19 patients who developed arrhythmias vs those without. Multivariate regression for adjusted odds ratios (aOR) and propensity score matching (PSM) were done to compare outcomes among both cohorts. A total of 1,664,240 patients (weighted) were hospitalized with COVID-19 infection, 380,915 (22.89%) of whom were diagnosed with an arrhythmia. After propensity matching COVID-19 with arrhythmias had higher rates of in-hospital mortality (22.4% vs 13.5%, P < 0.001), acute kidney injury (PSM 39.4% vs 35.7%, P < 0.001), acute heart failure (AHF) (18.2% vs 12.6%, P < 0.001), acute stroke (0.76% vs 0.57%, P < 0.001), cardiogenic shock (1.38% vs 0.5%, P < 0.001), cardiac arrest (5.26% vs 2.3%, P < 0.001) acute myocardial infarction (AMI) (12.8% vs 7.8%, P < 0.001), intracerebral hemorrhage (0.63% vs 0.45%, P < 0.001), major bleeding (2.6% vs 1.8%, P < 0.001) and endotracheal intubation (17.04% vs 10.17% < 0.001) compared to arrhythmias without COVID-19. This cohort also had lower odds of receiving interventions such as cardiac pacing (aOR 0.15 95% Cl 0.13-0.189 P < 0.001), cardioversion (aOR 0.43 95% CI 0.40-0.46, P < 0.001), and defibrillator (aOR 0.087 95% Cl 0.061-0.124, P < 0.001) compared to arrhythmia patients without COVID-19. Cardiac arrhythmias associated with COVID-19 resulted in longer length of hospital stay and higher total costs of hospitalizations. Arrhythmias associated with COVID-19 had worse clinical outcomes with an increased rate of in-hospital mortality, longer length of hospital stay, and higher total cost. These patients also had lower odds of receiving interventions during the index hospitalization.

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.

Low Prevalence of Late Myocardial Injury on Cardiac MRI Following COVID-19 Infection

BACKGROUND

The prevalence of abnormal cardiac magnetic resonance imaging (MRI) findings indicative of myocardial injury in patients who recovered from coronavirus disease 2019 (COVID-19) is currently unclear, with a high variability in the reported prevalence.

PURPOSE

To assess the prevalence of myocardial injury after a COVID-19 infection.

STUDY TYPE

Prospective, bicentric study.

SUBJECTS

Seventy consecutive patients who recovered from COVID-19 and were previously hospitalized. Mean age was 57 years and 39% of the patients were female. Ten healthy controls and a comparator group of 75 nonischemic cardiomyopathy (NICM) patients were employed.

FIELD STRENGTH/SEQUENCE

1.5-T, steady-state free precession (SSFP) gradient-echo sequence, modified Look-Locker inversion recovery sequence with balanced SSFP readout, T2-prepared spiral readout sequence and a T1-weighted inversion recovery fast gradient-echo sequence was acquired ~4-5 months after recovery from COVID-19.

ASSESSMENT

The SSFP sequence was utilized for the calculation of left and right ventricular volumes and ejection fractions (LVEF and RVEF) following manual endocardial contouring. T1 and T2 mapping was performed by pixel-wise exponential fitting, and T1 and T2 values were computed by manual contouring of the left ventricular endocardial and epicardial walls. Late gadolinium enhancement (LGE) images were graded qualitatively as LGE present or absent.

STATISTICAL TESTS

T-tests and the χ2 or Fisher's exact tests were used to compare continuous and categorical variables respectively between the COVID-19 and NICM groups. Inter-rater agreement was evaluated by the intraclass correlation coefficient for continuous variables and Cohen's kappa test for LGE.

RESULTS

Reduced RVEF occurred in 10%, LGE and elevated native T1 in 9%, reduced LVEF in 4%, and elevated T2 in 3% of COVID-19 patients, respectively. Patients with NICM had lower mean LVEF (41.6% ± 6% vs. 60% ± 7%), RVEF (46% ± 5% vs. 61% ± 9%), and a significantly higher prevalence of LGE (27% vs. 9%) when compared to those post-COVID-19.

DATA CONCLUSION

Abnormal cardiac MRI findings may show a low prevalence in patients who recovered from COVID-19 and were previously hospitalized.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

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.

Image Timing After COVID-19 Infection in Athletes

BACKGROUND

Coronavirus disease 2019 (COVID-19) has significantly impacted National Collegiate Athletic Association (NCAA) athletics, with specific concerns for cardiac involvement after infection. Pericardial abnormalities have been seen in up to 39.5% of athletes after COVID-19 infection, while myocardial involvement has been reported at a lower rate of 2.7%. To date, myocardial injury has been seen in 0.6% to 0.7% of athletes when using symptom screening and imaging as clinically indicated, which increases to 2.3% to 3.0% when all athletes with COVID-19 undergo cardiac magnetic resonance (CMR) imaging.

PURPOSE

This study will examine whether there exists an ideal time from positive COVID-19 results to obtaining imaging to increase the likelihood of finding abnormalities.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

NCAA athletes at West Virginia University who were found to be COVID-19 positive on routine screening were required to undergo echocardiography (ECG) and CMR. These data were reviewed by cardiology and determined to be normal or abnormal. Statistical analysis with logistic regression and descriptive statistics was performed to evaluate whether a time existed where abnormalities on imaging were most likely to be found.

RESULTS

A total of 41 athletes were included in this study. ECG was performed earlier on average than CMR imaging, at 18.2 days versus 27.5 days. No significant difference was found in timing from COVID-19 infection diagnosis and abnormalities seen on imaging for either ECG or CMR imaging.

CONCLUSION

The risk of cardiac involvement in athletes in the setting of COVID-19 has already been documented. This study suggests that imaging timing is independent of cardiac involvement with no correlation to specific time periods where more abnormalities may be found. However, CMR imaging showing changes at day 54 after infection suggests cardiac findings can be seen months after imaging.

CLINICAL RELEVANCE

Cardiac imaging for athletes after contracting COVID-19 does not show a significant relationship to time of imaging. However, given the cardiac involvement seen months after diagnosis, further examination of prolonged cardiac effects must be carried out.

Coronary microvascular health in symptomatic patients with prior COVID-19 infection: an updated analysis

AIMS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with endothelial dysfunction. We aimed to determine the effects of prior coronavirus disease 2019 (COVID-19) on the coronary microvasculature accounting for time from COVID-19, disease severity, SARS-CoV-2 variants, and in subgroups of patients with diabetes and those with no known coronary artery disease.

METHODS AND RESULTS

Cases consisted of patients with previous COVID-19 who had clinically indicated positron emission tomography (PET) imaging and were matched 1:3 on clinical and cardiovascular risk factors to controls having no prior infection. Myocardial flow reserve (MFR) was calculated as the ratio of stress to rest myocardial blood flow (MBF) in mL/min/g of the left ventricle. Comparisons between cases and controls were made for the odds and prevalence of impaired MFR (MFR < 2). We included 271 cases matched to 815 controls (mean ± SD age 65 ± 12 years, 52% men). The median (inter-quartile range) number of days between COVID-19 infection and PET imaging was 174 (58-338) days. Patients with prior COVID-19 had a statistically significant higher odds of MFR <2 (adjusted odds ratio 3.1, 95% confidence interval 2.8-4.25 P < 0.001). Results were similar in clinically meaningful subgroups. The proportion of cases with MFR <2 peaked 6-9 months from imaging with a statistically non-significant downtrend afterwards and was comparable across SARS-CoV-2 variants but increased with increasing severity of infection.

CONCLUSION

The prevalence of impaired MFR is similar by duration of time from infection up to 1 year and SARS-CoV-2 variants, but significantly differs by severity of infection.

Cardiac changes in collegiate athletes following SARS-CoV-2 infection and quarantine: a prospective Case-Control study

OBJECTIVE

Athletes are susceptible to acute respiratory tract infections, including SARS-CoV-2, which can affect cardiovascular function. We aimed to evaluate the impact of COVID-19 infection and quarantine on cardiac function in male and female collegiate athletes.

METHODS

We conducted a single-center, prospective, case-control study and performed transthoracic echocardiography in a diverse group of convalescent SARS-CoV-2-positive athletes following a 10-14-day quarantine, matched to non-SARS-CoV-2 athletes. Data collection occurred from August 1, 2020, to May 31, 2021.

RESULTS

We evaluated 61 SARS-CoV-2-positive athletes (20 ± 1 years, 39% female) and 61 controls (age 20 ± 2 years, 39% female). Echocardiography in SARS-CoV-2-positive athletes was performed on average 40 ± 38 days after infection diagnosis. All SARS-CoV-2-positive athletes had clinically normal systolic left ventricular function (LVEF > 50%). However, SARS-CoV-2-positive athletes exhibited mildly lower LVEF compared to controls (65 ± 6% vs. 72 ± 8%, respectively, p < 0.001), which remained significant when evaluated separately for female and male athletes. Sub-analysis revealed these differences occurred only when imaging occurred within a mean average of 27 days of infection, with a longer recovery period (≥27 days) resulting in no differences. SARS-CoV-2-positive male athletes exhibited higher left ventricular end-diastolic volume and mitral filling velocities compared to male controls.

CONCLUSION

Our study reveals unique sex-specific cardiac changes in collegiate athletes following SARS-CoV-2 infection and quarantine compared to controls. Despite a mild reduction in LVEF, which was only observed in the first weeks following infection, no clinically significant cardiac abnormalities were observed. Further research is required to understand if the changes in LVEF are directly attributed to the infection or indirectly through exercise restrictions resulting from quarantine.

Cardiac Involvement Due to COVID-19: Insights from Imaging and Histopathology

Lingering cardiac symptoms are increasingly recognised complications of severe acute respiratory syndrome coronavirus 2 infection, now referred to as post-acute cardiovascular sequelae of COVID-19 (PASC). In the acute phase, cardiac injury is driven by cytokine release and stems from ischaemic and thrombotic complications, resulting in myocardial necrosis. Patients with pre-existing cardiac conditions are particularly vulnerable. Myocarditis due to a direct viral infection is rare. Chronic symptoms relate to either worsening of pre-existing heart disease (PASC - cardiovascular disease) or delayed chronic inflammatory condition due to heterogenous immune dysregulation (PASC - cardiovascular syndrome), the latter affecting a broad segment of previously well people. Both PASC presentations are associated with increased cardiovascular risk, long-term disability and reduced quality of life. The recognition and management of PASC in clinical settings remains a considerable challenge. Sensitive diagnostic methods are needed to detect subtler inflammatory changes that underlie the persistent symptoms in PASC - cardiovascular syndrome, alongside considerable clinical experience in inflammatory cardiac conditions.

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.

Improving collegiate student-athletes' well-being: exploring the roles of openness to experience, knowledge sharing and perceived coaching effectiveness

Introduction

Collegiate student-athletes often encounter various stressors stemming from academic study and athletic training, which can potentially have negative effects on their well-being. This study investigates how collegiate student-athletes' openness to experience and their engagement in knowledge sharing influence their well-being, as well as the moderating role of perceived coaching effectiveness.

Methods

To examine these relationships, we propose and test a conceptual framework using an online survey conducted among collegiate student-athletes from a southeastern province of China. The participants consisted of 484 collegiate student-athletes who voluntarily participated in the study. We used regression analysis and mediation analysis to test the proposed relationships among the variables.

Results

Openness to experience has a positive impact on knowledge sharing (β = 0.552, p < 0.05); knowledge sharing with peers positively affects collegiate student-athlete well-being (β = 0.415, p < 0.05) and mediates the relationship between openness to experience and collegiate student-athlete well-being (β = 0.086, p < 0.05). Perceived coaching effectiveness positively moderates the relationship between openness to experience and knowledge sharing (β = 0.170, p < 0.05).

Discussion

Our study contributes to the collegiate student-athlete literature by shedding light on the factors that influence their well-being, with insights that bear important managerial implications for universities and coaches.

Multimodality Cardiac Imaging in COVID

Infection with SARS-CoV-2, the virus that causes COVID, is associated with numerous potential secondary complications. Global efforts have been dedicated to understanding the myriad potential cardiovascular sequelae which may occur during acute infection, convalescence, or recovery. Because patients often present with nonspecific symptoms and laboratory findings, cardiac imaging has emerged as an important tool for the discrimination of pulmonary and cardiovascular complications of this disease. The clinician investigating a potential COVID-related complication must account not only for the relative utility of various cardiac imaging modalities but also for the risk of infectious exposure to staff and other patients. Extraordinary clinical and scholarly efforts have brought the international medical community closer to a consensus on the appropriate indications for diagnostic cardiac imaging during this protracted pandemic. In this review, we summarize the existing literature and reference major societal guidelines to provide an overview of the indications and utility of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging for the diagnosis of cardiovascular complications of COVID.

Considerations after lockdown and overcoming Covid-19: A systematic review for returning to safe physical exercise practice

Objective

This systematic review aims to understand the problems associated with lockdown and the various conditions of Covid-19 infection and to help prepare athletes and exercise enthusiasts for the safe resumption of sport in a manner that promotes wellness, healthy competition, and a sports industry that survives the current situation. This systematic review was carried out, following the recommendations of the currently pre-established reporting elements for systematic reviews and meta-analyses. The following databases were consulted: ISI Web of Science (WOS), Scopus and Google Scholar. This review includes a total of 19 articles.

News

The results are presented based on three predominant themes: (1) psychological impact produced by SARS-CoV-2; (2) post-Covid-19 cardiac abnormalities and (3) protocols for an adequate return to physical practice.

Prospects and projects

Most of the protocols shown by the various papers are consistent in terms of duration and number of phases. Based on this, the safe return to practice protocol can be divided into four stages of seven days in each phase in order to progress according to the symptoms perceived. In each phase, the physiological demand and efforts necessary to cover the proposed activities are increased until optimal physical condition is recovered.

Cardiopulmonary Phenotypes of Post Acute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2: A Narrative Review

The acute effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are well known; however, the long-term cardiopulmonary effects are less well characterized. The phenotypic expression of acute infection is heterogeneous, ranging from a complete absence of symptoms to shock, multisystem organ failure, and death. Patients with severe or critical coronavirus disease (COVID-19) who survive their initial illness can require a prolonged period of recovery lasting weeks to months. This specific patient group is part of a larger and even more heterogeneous group of patients who initially experience mild-to-moderate symptoms that fail to resolve over time. Collectively, patients recovering from severe or critical COVID-19 and those who continue to experience symptoms following a lower acuity infection are considered to have Post Acute Sequalae of SARS-CoV-2 infection (PASC). Using prognostic factors like myocardial infarction, myocarditis, pulmonary embolism, acute respiratory distress syndrome, need for mechanical ventilation or extracorporeal membrane oxygenation, and advanced pharmaceutical therapies that primarily occur or are instituted in the acute phase of illness one can begin to develop a taxonomy or corpus of PASC in its varied forms.

Long-term prognostic impact of subclinical myocardial dysfunction in patients recovered from COVID-19

BACKGROUND

Cardiovascular sequelae may occur in patients recovered from coronavirus disease 2019 (COVID-19). Recent studies have detected a considerable incidence of subclinical myocardial dysfunction-assessed with speckle-tracking echocardiography-and of long-COVID symptoms in these patients. This study aimed to define the long-term prognostic role of subclinical myocardial dysfunction and long-COVID condition in patients recovered from COVID-19 pneumonia.

METHODS

We prospectively followed up 110 patients hospitalized at our institution due to COVID-19 pneumonia in April 2020 and then recovered from SARS-CoV-2 infection. A 7-month clinical and echocardiographic evaluation was performed, followed by a 21-month clinical follow-up. The primary outcome was major adverse cardiovascular events (MACE), a composite of myocardial infarction, stroke, heart failure hospitalization, and all-cause mortality.

RESULTS

A subclinical myocardial dysfunction-defined as an impairment of left ventricular global longitudinal strain (≥-18%)-was identified at a 7-month follow-up in 37 patients (34%), was associated with an increased risk of long-term MACE with a good discriminative power (area under the curve: .73) and resulted in a strong independent predictor of extended MACE in multivariate regression analyses. Long-COVID condition was not associated with a worse long-term prognosis, instead.

CONCLUSIONS

In patients recovered from COVID-19 pneumonia, a subclinical myocardial dysfunction is present in one-third of the whole population at 7-month follow-up and is associated with a higher risk of MACE at long-term follow-up. Speckle-tracking echocardiography is a promising tool to optimize the risk-stratification in patients recovered from COVID-19 pneumonia, while the definition of a long-COVID condition has no prognostic relevance.

A Case of Pure Pericarditis Associated With COVID-19: Application of Classical Clinical Evaluation for Differential Diagnosis

Pericarditis of varying severity is being recognized as a rare complication of the COVID-19 infection. We present a patient with an electrocardiogram (EKG) and physical exam findings that initially seemed to most likely be pericarditis related to the COVID-19 infection. The differential diagnosis was a bit difficult because it included ST-segment elevation myocardial infarction (STEMI) due to some EKG changes and early repolarization changes that were rather robust. Treatment options for STEMI could cause severe harm if the process turned out to be pericarditis. Treatment options for pericarditis could cause severe harm if the process turned out to be STEMI. And treatment options for early repolarization might be no treatment at all, which could cause harm if the process turned out to be STEMI or pericarditis. In this case, a correct diagnosis was very important to ensure a good clinical outcome. We would like to share our thought processes in the management of this case.

Cardiovascular magnetic resonance for evaluation of cardiac involvement in COVID-19: recommendations by the Society for Cardiovascular Magnetic Resonance

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that has affected nearly 600 million people to date across the world. While COVID-19 is primarily a respiratory illness, cardiac injury is also known to occur. Cardiovascular magnetic resonance (CMR) imaging is uniquely capable of characterizing myocardial tissue properties in-vivo, enabling insights into the pattern and degree of cardiac injury. The reported prevalence of myocardial involvement identified by CMR in the context of COVID-19 infection among previously hospitalized patients ranges from 26 to 60%. Variations in the reported prevalence of myocardial involvement may result from differing patient populations (e.g. differences in severity of illness) and the varying intervals between acute infection and CMR evaluation. Standardized methodologies in image acquisition, analysis, interpretation, and reporting of CMR abnormalities across would likely improve concordance between studies. This consensus document by the Society for Cardiovascular Magnetic Resonance (SCMR) provides recommendations on CMR imaging and reporting metrics towards the goal of improved standardization and uniform data acquisition and analytic approaches when performing CMR in patients with COVID-19 infection.

Myocardial Tissue Characterization in Cardiac Magnetic Resonance Studies of Patients Recovering From COVID-19: A Meta-Analysis

Background Meta-analysis can identify biological factors that moderate cardiac magnetic resonance myocardial tissue markers such as native T1 (longitudinal magnetization relaxation time constant) and T2 (transverse magnetization relaxation time constant) in cohorts recovering from COVID-19 infection. Methods and Results Cardiac magnetic resonance studies of patients with COVID-19 using myocardial T1, T2 mapping, extracellular volume, and late gadolinium enhancement were identified by database searches. Pooled effect sizes and interstudy heterogeneity (I2) were estimated with random effects models. Moderators of interstudy heterogeneity were analyzed by meta-regression of the percent difference of native T1 and T2 between COVID-19 and control groups (%ΔT1 [percent difference of the study-level means of myocardial T1 in patients with COVID-19 and controls] and %ΔT2 [percent difference of the study-level means of myocardial T2 in patients with COVID-19 and controls]), extracellular volume, and the proportion of late gadolinium enhancement. Interstudy heterogeneities of %ΔT1 (I2=76%) and %ΔT2 (I2=88%) were significantly lower than for native T1 and T2, respectively, independent of field strength, with pooled effect sizes of %ΔT1=1.24% (95% CI, 0.54%-1.9%) and %ΔT2=3.77% (95% CI, 1.79%-5.79%). %ΔT1 was lower for studies in children (median age: 12.7 years) and athletes (median age: 21 years), compared with older adults (median age: 48 years). Duration of recovery from COVID-19, cardiac troponins, C-reactive protein, and age were significant moderators for %ΔT1 and/or %ΔT2. Extracellular volume, adjusted by age, was moderated by recovery duration. Age, diabetes, and hypertension were significant moderators of the proportion of late gadolinium enhancement in adults. Conclusions T1 and T2 are dynamic markers of cardiac involvement in COVID-19 that reflect the regression of cardiomyocyte injury and myocardial inflammation during recovery. Late gadolinium enhancement and to a lesser extent extracellular volume, are more static biomarkers moderated by preexisting risk factors linked to adverse myocardial tissue remodeling.

COVID-19: Insights into long-term manifestations and lockdown impacts

Coronaviruses are pathogens thought to primarily affect the respiratory tracts of humans. The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2019 was also marked mainly by its symptoms of respiratory illness, which were named coronavirus disease 2019 (COVID-19). Since its initial discovery, many other symptoms have been linked to acute SARS-CoV-2 infections as well as to the long-term outcomes of COVID-19 patients. Among these symptoms are different categories of cardiovascular diseases (CVDs), which continue to be the main cause of death worldwide. The World Health Organization estimates that 17.9 million people die from CVDs each year, accounting for ∼32% of all deaths globally. Physical inactivity is one of the most important behavioral risk factors for CVDs. The COVID-19 pandemic has affected CVDs as well as the physical activity in different ways. Here, we provide an overview of the current status as well as future challenges and possible solutions.

Subclinical cardiac involvement in student athletes after COVID-19 infection - Evaluation using feature tracking cardiac MRI strain analysis

OBJECTIVES

To evaluate subclinical cardiac dysfunction in student athletes after COVID-19 infection using feature tracking cardiac MRI strain analysis.

METHODS

Student athletes with history of COVID-19 infection underwent cardiac MRI as part of screening before return to competitive play. Subjects were enrolled if they had no or mild symptoms, normal cardiac MRI findings with no imaging evidence of myocarditis. Feature tracking strain analysis was performed using short and long axis cine MRI images of athletes and a separate cohort of healthy controls. Differences between the cardiac strain parameters were statistically analyzed by Mann-Whitney U test.

RESULTS

The study cohort included 122 athletes (49 females, mean age 20 years ± 1.5 standard deviations) who had a history of COVID-19, and 35 healthy controls (24 females, mean age 34 years ± 18 standard deviations). COVID-19 positive athletes had normal physiologic cardiac adaptations, including significantly higher left and right ventricle end-diastolic volumes (p = 0.00001) when compared to healthy controls. There was no significant difference between biventricular ejection fraction between athletes and control subjects (p > 0.05). Cardiac MRI parameters, including left ventricle global longitudinal strain (LV-GLS), global circumferential strain (LV-GCS), and global radial strain (LV-GRS) values were normal but slightly lower in athletes compared to controls. LV-GCS and LV-GRS were significantly lower in athletes compared to controls (p = 0.007 and p = 0.005 respectively), but there was no significant difference for LV-GLS (p = 0.088).

CONCLUSION

In this study of 122 athletes, there was no evidence of subclinical myocardial alterations following recovery from COVID-19 found on cardiac MRI strain analysis. When compared to healthy controls, the competitive athletes had higher end-diastolic volume indices and reduced, albeit normal, strain values of LV-GLS, LV-GCS, and LV-GRS.

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.

The Cardiac Effects of COVID-19 on Young Competitive Athletes: Results from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA)

The Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study is a large-scale prospective investigation evaluating the cardiovascular effects and outcomes of SARS-CoV-2 infection on young competitive athletes. This review provides an overview of the key results from the ORCCA study. Results from the ORCCA study have provided important insights into the clinical impact of SARS-CoV-2 infection on the cardiovascular health of young competitive athletes and informed contemporary screening and return to sport practices. Key results include defining a low prevalence of both cardiac involvement and adverse cardiovascular outcomes after SARS-CoV-2 infection and evaluating the utility of a return-to-play cardiac evaluation. Future aims of the ORCCA study include the longer-term evaluation of cardiovascular outcomes among athletes post-SARS-CoV-2 infection and the transition to investigating outcomes in young athletes with potentially high-risk genetic or structural cardiac diagnoses.

The Impact of COVID-19 on the Cardiovascular Health of Emerging Adults Aged 18-25: Findings From a Scoping Review

There is limited knowledge regarding the cardiovascular impact of coronavirus disease 2019 (COVID-19) on emerging adults aged 18-25, a group that disproportionately contracts COVID-19. To guide future cardiovascular disease (CVD) research, policy, and practice, a scoping review was conducted to: (i) examine the impact of the COVID-19 pandemic on the cardiovascular health of emerging adults; and (ii) identify strategies to screen for and manage COVID-19-related cardiovascular complications in this age group. A comprehensive search strategy was applied to several academic databases and grey literature sources. An updated search yielded 6738 articles, 147 of which were extracted and synthesized. Reports identified COVID-19-associated cardiac abnormalities, vascular alterations, and multisystem inflammatory syndrome in emerging adults; based on data from student-athlete samples, prevalence estimates of myocarditis and cardiac abnormalities were 0.5%-3% and 0%-7%, respectively. Obesity, hypertension, CVD, congenital heart disease, and marginalization are potential risk factors for severe COVID-19, related cardiovascular complications, and mortality in this age group. As a screening modality for COVID-19-associated cardiac involvement, it is recommended that cardiac magnetic resonance imaging be indicated by a positive cardiac history and/or abnormal "triad" testing (cardiac troponin, electrocardiogram, and transthoracic echocardiogram) to improve diagnostic utility. To foster long-term cardiovascular health among emerging adults, cardiorespiratory fitness, health literacy and education, and telehealth accessibility should be priorities of health policy and clinical practice. Ultimately, surveillance data from the broader emerging adult population will be crucial to assess the long-term cardiovascular impact of both COVID-19 infection and vaccination, guide screening and management protocols, and inform CVD prevention efforts.

Cardiac abnormalities in Long COVID 1-year post-SARS-CoV-2 infection

BACKGROUND

Long COVID is associated with multiple symptoms and impairment in multiple organs. Cross-sectional studies have reported cardiac impairment to varying degrees by varying methodologies. Using cardiac MR (CMR), we investigated a 12-month trajectory of abnormalities in Long COVID.

OBJECTIVES

To investigate cardiac abnormalities 1-year post-SARS-CoV-2 infection.

METHODS

534 individuals with Long COVID underwent CMR (T1/T2 mapping, cardiac mass, volumes, function and strain) and multiorgan MRI at 6 months (IQR 4.3-7.3) since first post-COVID-19 symptoms. 330 were rescanned at 12.6 (IQR 11.4-14.2) months if abnormal baseline findings were reported. Symptoms, questionnaires and blood samples were collected at both time points. CMR abnormalities were defined as ≥1 of low left or right ventricular ejection fraction (LVEF), high left or right ventricular end diastolic volume, low 3D left ventricular global longitudinal strain (GLS), or elevated native T1 in ≥3 cardiac segments. Significant change over time was reported by comparison with 92 healthy controls.

RESULTS

Technical success of multiorgan and CMR assessment in non-acute settings was 99.1% and 99.6% at baseline, and 98.3% and 98.8% at follow-up. Of individuals with Long COVID, 102/534 (19%) had CMR abnormalities at baseline; 71/102 had complete paired data at 12 months. Of those, 58% presented with ongoing CMR abnormalities at 12 months. High sensitivity cardiac troponin I and B-type natriuretic peptide were not predictive of CMR findings, symptoms or clinical outcomes. At baseline, low LVEF was associated with persistent CMR abnormality, abnormal GLS associated with low quality of life and abnormal T1 in at least three segments was associated with better clinical outcomes at 12 months.

CONCLUSION

CMR abnormalities (left entricular or right ventricular dysfunction/dilatation and/or abnormal T1mapping), occurred in one in five individuals with Long COVID at 6 months, persisting in over half of those at 12 months. Cardiac-related blood biomarkers could not identify CMR abnormalities in Long COVID.

TRIAL REGISTRATION NUMBER

NCT04369807.

Cardiologic Manifestations in Omicron-Type Versus Wild-Type COVID-19: A Systematic Echocardiographic Study

Background Information about the cardiac manifestations of the Omicron variant of COVID-19 is limited. We performed a systematic prospective echocardiographic evaluation of consecutive patients hospitalized with the Omicron variant of COVID-19 infection and compared them with similarly recruited patients were propensity matched with the wild-type variant. Methods and Results A total of 162 consecutive patients hospitalized with Omicron COVID-19 underwent complete echocardiographic evaluation within 24 hours of admission and were compared with propensity-matched patients with the wild-type variant (148 pairs). Echocardiography included left ventricular (LV) systolic and diastolic, right ventricular (RV), strain, and hemodynamic assessment. Echocardiographic parameters during acute infection were compared with historic exams in 62 patients with the Omicron variant and 19 patients with the wild-type variant who had a previous exam within 1 year. Of the patients, 85 (53%) had a normal echocardiogram. The most common cardiac pathology was RV dilatation and dysfunction (33%), followed by elevated LV filling pressure (E/e' ≥14, 29%) and LV systolic dysfunction (ejection fraction <50%, 10%). Compared with the matched wild-type cohort, patients with Omicron had smaller RV end-systolic areas (9.3±4 versus 12.3±4 cm²; P=0.0003), improved RV function (RV fractional-area change, 53.2%±10% versus 39.7%±13% [P<0.0001]; RV S', 12.0±3 versus 10.7±3 cm/s [P=0.001]), and higher stroke volume index (35.6 versus 32.5 mL/m²; P=0.004), all possibly related to lower mean pulmonary pressure (34.6±12 versus 41.1±14 mm Hg; P=0.0001) and the pulmonary vascular resistance index (P=0.0003). LV systolic or diastolic parameters were mostly similar to the wild-type variant-matched cohort apart from larger LV size. However, in patients who had a previous echocardiographic exam, these LV abnormalities were recorded before acute Omicron infection, but not in the wild-type cohort. Numerous echocardiographic parameters were associated with higher in-hospital mortality (LV ejection fraction, stroke volume index, E/e', RV S'). Conclusions In patients with Omicron, RV function is impaired to a lower extent compared with the wild-type variant, possibly related to the attenuated pulmonary parenchymal and/or vascular disease. LV systolic and diastolic abnormalities are as common as in the wild-type variant but were usually recorded before acute infection and probably reflect background cardiac morbidity. Numerous LV and RV abnormalities are associated with adverse outcome in patients with Omicron.

Utilization of Cardiovascular Magnetic Resonance Imaging for Resumption of Athletic Activities Following COVID-19 Infection: An Expert Consensus Document on Behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention Leadership and Endorsed by the Society for Cardiovascular Magnetic Resonance

The global pandemic of COVID-19 caused by infection with SARS-CoV-2 is now entering its fourth year with little evidence of abatement. As of December 2022, the World Health Organization Coronavirus (COVID-19) Dashboard reported 643 million cumulative confirmed cases of COVID-19 worldwide and 98 million in the United States alone as the country with the highest number of cases. Although pneumonia with lung injury has been the manifestation of COVID-19 principally responsible for morbidity and mortality, myocardial inflammation and systolic dysfunction though uncommon are well-recognized features that also associate with adverse prognosis. Given the broad swath of the population infected with COVID-19, the large number of affected professional, collegiate, and amateur athletes raises concern regarding the safe resumption of athletic activity (return to play) following resolution of infection. A variety of different testing combinations that leverage ECG, echocardiography, circulating cardiac biomarkers, and cardiovascular magnetic resonance imaging have been proposed and implemented to mitigate risk. Cardiovascular magnetic resonance in particular affords high sensitivity for myocarditis but has been employed and interpreted nonuniformly in the context of COVID-19 thereby raising uncertainty as to the generalizability and clinical relevance of findings with respect to return to play. This consensus document synthesizes available evidence to contextualize the appropriate utilization of cardiovascular magnetic resonance in the return to play assessment of athletes with prior COVID-19 infection to facilitate informed, evidence-based decisions, while identifying knowledge gaps that merit further investigation.

The effect of SARS-CoV-2 infection on cardiac function in post-COVID-19 survivors: A systematic review and meta-analysis

The longitudinal trajectories of cardiac structure and function following SARS-CoV-2 infection are unclear. Therefore, this meta-analysis aims to elucidate the effect of SARS-CoV-2 infection on cardiac function in coronavirus disease 2019 (COVID-19) survivors after recovery. PubMed/MEDLINE, CENTRAL, and EMBASE were systematically searched for articles published up to 1st August 2022. A systematic review and meta-analysis were performed to calculate the pooled effects size and 95% confidence interval of each outcome. A total of 21 studies including 2394 individuals (1436 post-COVID-19 cases and 958 controls) were included in the present meta-analysis. The pooled analyses compared with control groups showed a significant association between post-COVID-19 and reduced left ventricular ejection fraction (LV EF), LV end-diastolic volume (LV EDV), LV stroke volume (LV SV), mitral annular plane systolic excursion (MAPSE), global longitudinal strain, right ventricular EF (RV EF), RV EDV, RV ESV, RV SV, tricuspid annular plane systolic excursion, and increased LV mass. Subgroup analysis based on the severity of COVID-19 in the acute phase and subsequent chronic outcomes revealed that LV EF, MAPSE, RV EF, and RV ESV only decreased in studies including patients with a history of intensive care unit admission. Cardiac impairment after SARS-CoV-2 infection persisted in recovered COVID-19 patients even after 1 year. Future studies are warranted to determine the biological mechanisms underlying the long-term cardiovascular consequences of COVID-19.

COVID-19 and elite sport: Cardiovascular implications and return-to-play

Curtailing elite sports during the coronavirus disease 2019 (COVID-19) pandemic was necessary to prevent widespread viral transmission. Now that elite sport and international competitions have been largely restored, there is still a need to devise appropriate screening and management pathways for athletes with a history of, or current, COVID-19 infection. These approaches should support the decision-making process of coaches, sports medicine practitioners and the athlete about the suitability to return to training and competition activities. In the absence of longitudinal data sets from athlete populations, the incidence of developing prolonged and debilitating symptoms (i.e., Long COVID) that affects a return to training and competition remains a challenge to sports and exercise scientists, sports medicine practitioners and clinical groups. As the world attempts to adjust toward 'living with COVID-19' the very nature of elite and international sporting competition poses a risk to athlete welfare that must be screened for and managed with bespoke protocols that consider the cardiovascular implications for performance.

Utilization of cardiovascular magnetic resonance (CMR) imaging for resumption of athletic activities following COVID-19 infection: an expert consensus document on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention (CVRI) Leadership and endorsed by the Society for Cardiovascular Magnetic Resonance (SCMR)

The global pandemic of coronavirus disease 2019 (COVID-19) caused by infection with severe acute respiratory suyndrome coronavirus 2 (SARS-CoV-2) is now entering its 4th year with little evidence of abatement. As of December 2022, the World Health Organization Coronavirus (COVID-19) Dashboard reported 643 million cumulative confirmed cases of COVID-19 worldwide and 98 million in the United States alone as the country with the highest number of cases. While pneumonia with lung injury has been the manifestation of COVID-19 principally responsible for morbidity and mortality, myocardial inflammation and systolic dysfunction though uncommon are well-recognized features that also associate with adverse prognosis. Given the broad swath of the population infected with COVID-19, the large number of affected professional, collegiate, and amateur athletes raises concern regarding the safe resumption of athletic activity (return to play, RTP) following resolution of infection. A variety of different testing combinations that leverage the electrocardiogram, echocardiography, circulating cardiac biomarkers, and cardiovascular magnetic resonance (CMR) imaging have been proposed and implemented to mitigate risk. CMR in particular affords high sensitivity for myocarditis but has been employed and interpreted non-uniformly in the context of COVID-19 thereby raising uncertainty as to the generalizability and clinical relevance of findings with respect to RTP. This consensus document synthesizes available evidence to contextualize the appropriate utilization of CMR in the RTP assessment of athletes with prior COVID-19 infection to facilitate informed, evidence-based decisions, while identifying knowledge gaps that merit further investigation.

Hemorrhagic Cardiac Tamponade-An Unusual Threat in the COVID-19 Recovery Phase

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated.

Swimming competitions in the era of COVID-19: Lessons from successfully hosting the International Swimming League

Background

Organization of mass sport events in the COVID-19 era is utterly complicated. Containments measures, required to avoid a virus outbreak, force athletes to compete under circumstances they never experienced before, most likely having a deleterious effect on their performance.

Purpose

We aimed to design a so-called athlete-friendly bubble system for the International Swimming League 2020 event, which is strict enough to avoid a COVID-19 outbreak, but still provides a supportive environment for the athletes.

Methods

To avoid the feeling of imprisonment, athletes were permitted to spend a certain amount of time in the parks surrounding the hotels. Such alleviations were possible to apply with strict adherence to the hygienic and social distancing protocols and regular COVID-19 testing. Evaluation of every COVID-19 positive case was key, and if prolonged PCR positivity or false positive PCR result was identified, the unnecessary quarantine was planned to be lifted. Return to play protocol (RTP) was planned, in case of a COVID-19 infection of an athlete inside the bubble. To test, if the athlete-friendly system provided a supportive environment, we evaluated athlete performance.

Results

11,480 PCR tests were performed for 1,421 individuals. 63 COVID-19 positive cases were detected, of which 5 turned out to be clinically insignificant, either because of prolonged PCR positivity or because of a false positive result. 93.1% of the positive cases were detected in the local crew, while no athlete got infected inside the bubble, as the two infected athletes were tested positive upon arrival. RTP was provided for two athletes. 85% of the athletes showed improvement during the bubble and 8 world records were broken.

Conclusion

The applied protocol proved to be effective, as no athlete got infected inside the bubble, moreover, the athlete-friendly system supported the athletes to improve their 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.

What cannot be cured must be endured: The long-lasting effect of a COVID-19 infection on workplace productivity

The COVID-19 pandemic has triggered economic shock waves across the globe. Exploiting a natural experiment, this paper estimates how being infected with the virus shapes individual-level productivity after having recovered. Studying the performance of professional athletes in Germany and Italy and applying a staggered difference-in-differences design, we find that individual performance drops by around 6 percent after a previously infected athlete returns to the pitch. This striking deterioration remains persistent over time - amounting to 5% eight months after the infection. The effect increases with age and infection severity, and is spread disproportionally over the course of a match. We detect no productivity effects for other respiratory infections. We take these findings as first evidence that the pandemic might cause long-lasting effects on worker productivity and economic growth.

Resuming Training in High-Level Athletes After Mild COVID-19 Infection: A Multicenter Prospective Study (ASCCOVID-19)

Background

There is a paucity of data on cardiovascular sequelae of asymptomatic/mildly symptomatic SARS-Cov-2 infections (COVID).

Objectives

The aim of this prospective study was to characterize the cardiovascular sequelae of asymptomatic/mildly symptomatic COVID-19 among high/elite-level athletes.

Methods

950 athletes (779 professional French National Rugby League (F-NRL) players; 171 student athletes) were included. SARS-Cov-2 testing was performed at inclusion, and F-NRL athletes were intensely followed-up for incident COVID-19. Athletes underwent ECG and biomarker profiling (D-Dimer, troponin, C-reactive protein). COVID(+) athletes underwent additional exercise testing, echocardiography and cardiac magnetic resonance imaging (CMR).

Results

285/950 athletes (30.0%) had mild/asymptomatic COVID-19 [79 (8.3%) at inclusion (COVID(+)_prevalent); 206 (28.3%) during follow-up (COVID(+)_incident)]. 2.6% COVID(+) athletes had abnormal ECGs, while 0.4% had an abnormal echocardiogram. During stress testing (following 7-day rest), COVID(+) athletes had a functional capacity of 12.8 ± 2.7 METS with only stress-induced premature ventricular ectopy in 10 (4.3%). Prevalence of CMR scar was comparable between COVID(+) athletes and controls [COVID(+) vs. COVID(−); 1/102 (1.0%) vs 1/28 (3.6%)]. During 289 ± 56 days follow-up, one athlete had ventricular tachycardia, with no obvious link with a SARS-CoV-2 infection. The proportion with troponin I and CRP values above the upper-limit threshold was comparable between pre- and post-infection (5.9% vs 5.9%, and 5.6% vs 8.7%, respectively). The proportion with D-Dimer values above the upper-limit threshold increased when comparing pre- and post-infection (7.9% vs 17.3%, P = 0.01).

Conclusion

The absence of cardiac sequelae in pauci/asymptomatic COVID(+) athletes is reassuring and argues against the need for systematic cardiac assessment prior to resumption of training (clinicaltrials.gov; NCT04936503).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00469-0.

Short and mid-term characteristics of COVID-19 disease course in athletes: A high-volume, single-center study

INTRODUCTION

At the pandemic's beginning, significant concern has risen about the prevalence of myocardial involvement after SARS-CoV-2 infection. We assessed the cardiovascular burden of SARS-CoV-2 in a large cohort of athletes and identified factors that might affect the disease course. We included 633 athletes in our study on whom we performed extensive cardiology examinations after recovering from SARS-CoV-2 infection. More than half of the athletes (n = 322) returned for a follow-up examination median of 107 days after the commencement of their infection.

RESULTS

Troponin T positivity was as low as 1.4% of the athletes, where the subsequently performed examinations did not show definitive, ongoing myocardial injury. Altogether, 31% of the athletes' rapid training rebuild was hindered by persistent or reoccurring symptoms. Female athletes reported a higher prevalence of return to play (RTP) symptoms than their male counterparts (34% vs. 19%, p = 0.005). The development of long COVID symptoms was independently predicted by increasing age and acute symptoms' severity in a multiple regression model (AUC 0.75, CI 0.685-0.801). Athletes presenting with either or both cough and ferritin levels higher than >150 μg/L had a 4.1x (CI 1.78-9.6, p = 0.001) higher odds ratio of developing persistent symptoms.

CONCLUSION

While SARS-CoV-2 rarely affects the myocardium in athletes, about one in three of them experience symptoms beyond the acute phase. Identifying those athletes with a predisposition to developing long-standing symptoms may aid clinicians and trainers in finding the optimal return-to-play timing and training load rebuild pace.

A Review of Long COVID With a Special Focus on Its Cardiovascular Manifestations

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has been the cause of the century's worst pandemic so far: coronavirus disease 2019 (COVID-19). It has led to unprecedented mortality and morbidity, resulting in devastating consequences worldwide. The acute manifestations of COVID-19 including respiratory as well as multisystem involvement have been causes of great concern among physicians. However, the long-term effects of the coronavirus have left many patients battling with chronic symptoms, ranging from extreme fatigue to cardiomyopathy. In this article, we review the chronic manifestations of COVID-19 with a focus on cardiovascular manifestations. We discuss the pathophysiology, post-acute sequelae, clinical manifestations, approach to the laboratory diagnosis of cardiovascular manifestations of long COVID, and a proposed multidisciplinary treatment method. We also explore the relationship between vaccination and the long COVID syndrome.

Cardiopulmonary work up of patients with and without fatigue 6 months after COVID-19

The pathogenesis of long-Covid symptoms remains incompletely understood. Therefore, we aimed to determine cardiopulmonary limitations 6 months after surviving COVID-19 using pulmonary function tests, echocardiographic studies to the point of analysis of global-longitudinal-strain (GLS), which describes the cycling myocardium deformation and provides better data on left ventricular (LV) dysfunction than LV ejection fraction (LVEF), and validated questionnaires. Overall, 60 consecutive hospitalized patients were included (61 ± 2 years, 40% treated in the ICU). At follow-up (194 ± 3 days after discharge), fatigue was the most prevalent symptom (28%). Patients with fatigue were more symptomatic overall and characterized by worse quality of life (QoL) scores compared to patients without fatigue (all p < 0.05), mainly due to limited mobility and high symptom burden. While PFT variables and LVEF were normal in the vast majority of patients (LVEF = 52% (45-52%)), GLS was significantly reduced (- 15% (- 18 to - 14%)). However, GLS values were not different between patients with and without fatigue. In conclusion, fatigue was the most prevalent long-Covid symptom in our cohort, which was associated with worse QoL mainly due to limited mobility and the high burden of concomitant symptoms. Patients showed a subtle myocardial dysfunction 6 months after surviving COVID-19, but this did not relate to the presence of fatigue.

Cardiovascular manifestations identified by multi-modality imaging in patients with long COVID

Background

The possibility of permanent cardiovascular damage causing cardiovascular long COVID has been suggested; however, data are insufficient. This study investigated the prevalence of cardiovascular disorders, particularly in patients with cardiovascular long COVID using multi-modality imaging.

Methods

A total of 584 patients admitted to the hospital due to COVID-19 between January 2020 and September 2021 were initially considered. Upon outpatient follow-up, 52 (9%) were suspected to have cardiovascular long COVID, had complaints of chest pain, dyspnea, or palpitations, and were finally enrolled in this study. This study is registered with the Japanese University Hospital Medical Information Network (UMIN 000047978).

Results

Of 52 patients with long COVID who were followed up in the outpatient clinic for cardiovascular symptoms, cardiovascular disorders were present in 27% (14/52). Among them, 15% (8/52) had myocardial injury, 8% (4/52) pulmonary embolisms, and 4% (2/52) both. The incidence of a severe condition (36% [5/14] vs. 8% [3/38], p = 0.014) and in-hospital cardiac events (71% [10/14] vs. 24% [9/38], p = 0.002) was significantly higher in patients with cardiovascular disorders than in those without. A multivariate logistic regression analysis revealed that a severe condition (OR, 5.789; 95% CI 1.442–45.220; p = 0.017) and in-hospital cardiac events (OR, 8.079; 95% CI 1.306–25.657; p = 0.021) were independent risk factors of cardiovascular disorders in cardiovascular long COVID patients.

Conclusions

Suspicion of cardiovascular involvement in patients with cardiovascular long COVID in this study was approximately 30%. A severe condition during hospitalization and in-hospital cardiac events were risk factors of a cardiovascular sequalae in CV long COVID patients.

Long-term cardiac pathology in individuals with mild initial COVID-19 illness

Cardiac symptoms are increasingly recognized as late complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in previously well individuals with mild initial illness, but the underlying pathophysiology leading to long-term cardiac symptoms remains unclear. In this study, we conducted serial cardiac assessments in a selected population of individuals with Coronavirus Disease 2019 (COVID-19) with no previous cardiac disease or notable comorbidities by measuring blood biomarkers of heart injury or dysfunction and by performing magnetic resonance imaging. Baseline measurements from 346 individuals with COVID-19 (52% females) were obtained at a median of 109 days (interquartile range (IQR), 77-177 days) after infection, when 73% of participants reported cardiac symptoms, such as exertional dyspnea (62%), palpitations (28%), atypical chest pain (27%) and syncope (3%). Symptomatic individuals had higher heart rates and higher imaging values or contrast agent accumulation, denoting inflammatory cardiac involvement, compared to asymptomatic individuals. Structural heart disease or high levels of biomarkers of cardiac injury or dysfunction were rare in symptomatic individuals. At follow-up (329 days (IQR, 274-383 days) after infection), 57% of participants had persistent cardiac symptoms. Diffuse myocardial edema was more pronounced in participants who remained symptomatic at follow-up as compared to those who improved. Female gender and diffuse myocardial involvement on baseline imaging independently predicted the presence of cardiac symptoms at follow-up. Ongoing inflammatory cardiac involvement may, at least in part, explain the lingering cardiac symptoms in previously well individuals with mild initial COVID-19 illness.

CMR findings after COVID-19 and after COVID-19-vaccination-same but different?

Cardiac involvement has been described in varying proportions of patients recovered from COVID-19 and proposed as a potential cause of prolonged symptoms, often described as post-COVID or long COVID syndrome. Recently, cardiac complications have been reported from COVID-19 vaccines as well. We aimed to compare CMR-findings in patients with clinical cardiac symptoms after COVID-19 and after vaccination. From May 2020 to May 2021, we included 104 patients with suspected cardiac involvement after COVID-19 who received a clinically indicated cardiac magnetic resonance (CMR) examination at a high-volume center. The mean time from first positive PCR to CMR was 112  ± 76 days. During their COVID-19 disease, 21% of patients required hospitalization, 17% supplemental oxygen and 7% mechanical ventilation. In 34 (32.7%) of patients, CMR provided a clinically relevant diagnosis: Isolated pericarditis in 10 (9.6%), %), acute myocarditis (both LLC) in 7 (6.7%), possible myocarditis (one LLC) in 5 (4.8%), ischemia in 4 (3.8%), recent infarction in 2 (1.9%), old infarction in 4 (3.8%), dilated cardiomyopathy in 3 (2.9%), hypertrophic cardiomyopathy in 2 (1.9%), aortic stenosis, pleural tumor and mitral valve prolapse each in 1 (1.0%). Between May 2021 and August 2021, we examined an additional 27 patients with suspected cardiac disease after COVID-19 vaccination. Of these, CMR provided at least one diagnosis in 22 (81.5%): Isolated pericarditis in 4 (14.8%), acute myocarditis in 9 (33.3%), possible myocarditis (acute or subsided) in 6 (22.2%), ischemia in 3 (37.5% out of 8 patients with stress test), isolated pericardial effusion (> 10 mm) and non-compaction-cardiomyopathy each in 1 (3.7%). The number of myocarditis diagnoses after COVID-19 was highly dependent on the stringency of the myocarditis criteria applied. When including only cases of matching edema and LGE and excluding findings in the right ventricular insertion site, the number of cases dropped from 7 to 2 while the number of cases after COVID-19 vaccination remained unchanged at 9. While myocarditis is an overall rare side effect after COVID-19 vaccination, it is currently the leading cause of myocarditis in our institution due to the large number of vaccinations applied over the last months. Contrary to myocarditis after vaccination, LGE and edema in myocarditis after COVID-19 often did not match or were confined to the RV-insertion site. Whether these cases truly represent myocarditis or a different pathological entity is to be determined in further studies.