SARS-CoV2 infection: functional and morphological cardiopulmonary changes in elite handball players

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.

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.

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.

Rating of Perceived Exertion Associated With Acute Symptoms in Athletes With Recent SARS-CoV-2 Infection: Athletes With Acute Respiratory InfEction (AWARE) VI Study

CONTEXT

SARS-CoV-2 infection can affect the exercise response in athletes. Factors associated with the exercise response have not been reported.

OBJECTIVE

To (1) describe heart rate (HR), systolic blood pressure (SBP), and rating of perceived exertion (RPE) responses to exercise in athletes with a recent SARS-CoV-2 infection and (2) identify factors affecting exercise responses.

DESIGN

Cross-sectional, experimental study.

PATIENTS OR OTHER PARTICIPANTS

Male and female athletes (age = 24.2 ± 6.3 years) with a recent (<28 days) SARS-CoV-2 infection (n = 72).

SETTING

A COVID-19 Recovery Clinic for athletes.

MAIN OUTCOME MEASURE(S)

Heart rate, SBP, and RPE were measured during submaximal exercise (modified Bruce protocol) at 10 to 28 days after SARS-CoV-2 symptom onset. Selected factors (demographics, sport, comorbidities, preinfection training variables, and symptoms during the acute phase of the infection) affecting the exercise response were analyzed using random coefficient (linear mixed) models.

RESULTS

Heart rate, SBP, and RPE increased progressively from rest to stage 5 of the exercise test (P = .0001). At stage 5 (10.1 metabolic equivalents), a higher HR and a higher SBP during exercise were associated with younger age (P = .0007) and increased body mass index (BMI; P = .009), respectively. Higher RPE during exercise was significantly associated with a greater number of whole-body (P = .006) and total number (P = .004) of symptoms during the acute phase of infection.

CONCLUSIONS

A greater number of symptoms during the acute infection was associated with a higher RPE during exercise in athletes at 10 to 28 days after SARS-CoV-2 infection. We recommend measuring RPE during the first exercise challenge after infection, as this may indicate disease severity and be valuable for tracking progress, recovery, and return to sport.

Assessment of myocardial function and cardiac performance using left ventricular global longitudinal strain in athletes after COVID-19: a follow-up study

Background

It has not yet been conclusively determined whether reduced left ventricular global longitudinal strain (LV GLS) after COVID-19 contributes to a reduction in exercise capacity. Our own studies showed a possible mild myocardial involvement in the form of reduced LV GLS in athletes after COVID-19 compared with healthy athletes. The aims of this prospective follow-up study were to investigate the development of LV GLS over a 3-month period in athletes after COVID-19 and the possible relationship between LV GLS and physical performance.

Methods

LV GLS was determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 96 recreational athletes (mean age 33.15 ± 12.40 years, 53 male, peak VO2 38.82 ± 11.14 ml/min/kg) at a median of two (t0) and five months (t1) after COVID-19. Cardiopulmonary exercise testing (CPET) was performed on a bicycle ergometer on both examination dates.

Results

LV GLS improved significantly between t0 and t1 (t0 -18.82 ± 2.02 vs. t1 -19.46 ± 2.05, p < 0.001). Echocardiographic and spiroergometric parameters were within the normal clinical reference range. Maximum power increased significantly from t0 to t1 (t0 283.17 ± 83.20 vs. t1 286.24 ± 85.22 Watt, p = 0.009) and there was a trend toward increased peak oxygen uptake (t0 36.82 ± 11.14 vs. t1 38.68 ± 10.26 ml/min/kg, p = 0.069). We found no correlation between LV GLS and performance parameters, except for the respiratory exchange ratio (RER) [ρ -0.316, (-0.501; -0.102), p < 0.050].

Conclusions

Significant improvement in LV GLS approximately five months after COVID-19 may be due to mild myocardial involvement during or shortly after COVID-19, which seems to recover. There was no correlation between LV GLS and performance parameters, except for an inverse correlation of LV GLS and RER, suggesting insufficient exercise intolerance at lower GLS values. Further studies on the development of GLS in athletes or in the general population with moderate and severe disease courses would be informative as well as the comparison of pre-COVID-19 with post-COVID-19 echocardiography to evaluate the effects of COVID-19 on cardiac function.

Left Ventricular Global Longitudinal Strain as a Parameter of Mild Myocardial Dysfunction in Athletes after COVID-19

Whether symptoms during COVID-19 contribute to impaired left ventricular (LV) function remains unclear. We determine LV global longitudinal strain (GLS) between athletes with a positive COVID-19 test (PCAt) and healthy control athletes (CON) and relate it to symptoms during COVID-19. GLS is determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 88 PCAt (35% women) (training at least three times per week/>20 MET) and 52 CONs from the national or state squad (38% women) at a median of two months after COVID-19. The results show that the GLS is significantly lower (GLS -18.53 ± 1.94% vs. -19.94 ± 1.42%, p < 0.001) and diastolic function significantly reduces (E/A 1.54 ± 0.52 vs. 1.66 ± 0.43, p = 0.020; E/E'l 5.74 ± 1.74 vs. 5.22 ± 1.36, p = 0.024) in PCAt. There is no association between GLS and symptoms like resting or exertional dyspnea, palpitations, chest pain or increased resting heart rate. However, there is a trend toward a lower GLS in PCAt with subjectively perceived performance limitation (p =0.054). A significantly lower GLS and diastolic function in PCAt compared with healthy peers may indicate mild myocardial dysfunction after COVID-19. However, the changes are within the normal range, so that clinical relevance is questionable. Further studies on the effect of lower GLS on performance parameters are necessary.

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.

[Effect of hyperoxic inhalations for athletes of different sports, including those who had COVID-19, when training in the middle altitude]

OBJECTIVE

To identify hyperoxic inhalations on the functional state of the cardiorespiratory system of athletes of different sports, who have previously had COVID-19, when training in the middle altitude.

MATERIAL AND METHODS

The study included 64 elite athletes during the preparatory period. The studies were conducted in Kislovodsk in the middle altitude (1240 meters) on the Maloe Sedlo mountain, in the conditions of training camps. We studied the parameters of heart rate variability and functional state of cardiovascular and respiratory systems. Hyperoxic inhalations were performed with the JAY-10 oxygen concentrator (LONGFIAN SCITECH CO., LTD., China). The oxygen concentration in the mixture was 93±3%, capacity - 5 l/min, exposure time - 20 min.

RESULTS

Athletes specializing in sports with predominantly anaerobic lactate and mixed mechanism of energy supply, respectively experiencing hypoxia in the process of their athletic activity during training can experience hypoxia at rest as well. The state of hypoxia during exercise in the middle altitude in such athletes is shown in heart rate variability indices (high values of heart rate and stress index, low power of high frequency waves), low saturation, increased oxygen uptake from the blood microcirculation system. The use of oxygen therapy in athletes promotes positive dynamics of the functional state, consisting in a reduced stress of regulatory mechanisms, strengthened tone of the parasympathetic nervous system in the heart rate regulation, increased economization of the central hemodynamics' parameters, improved functions of the external respiratory system.

CONCLUSION

Application of hyperoxic inhalations during intense exercise in the middle altitude has a favorable effect on the functional state of the cardiorespiratory system in all the studied sports, especially in athletes who have previously had COVID-19.

Long COVID: mechanisms, risk factors and recovery

NEW FINDINGS

What is the topic of this review? The emerging condition of long COVID, its epidemiology, pathophysiological impacts on patients of different backgrounds, physiological mechanisms emerging as explanations of the condition, and treatment strategies being trialled. The review leads from a Physiological Society online conference on this topic. What advances does it highlight? Progress in understanding the pathophysiology and cellular mechanisms underlying Long COVID and potential therapeutic and management strategies.

ABSTRACT

Long COVID, the prolonged illness and fatigue suffered by a small proportion of those infected with SARS-CoV-2, is placing an increasing burden on individuals and society. A Physiological Society virtual meeting in February 2022 brought clinicians and researchers together to discuss the current understanding of long COVID mechanisms, risk factors and recovery. This review highlights the themes arising from that meeting. It considers the nature of long COVID, exploring its links with other post-viral illnesses such as myalgic encephalomyelitis/chronic fatigue syndrome, and highlights how long COVID research can help us better support those suffering from all post-viral syndromes. Long COVID research started particularly swiftly in populations routinely monitoring their physical performance - namely the military and elite athletes. The review highlights how the high degree of diagnosis, intervention and monitoring of success in these active populations can suggest management strategies for the wider population. We then consider how a key component of performance monitoring in active populations, cardiopulmonary exercise training, has revealed long COVID-related changes in physiology - including alterations in peripheral muscle function, ventilatory inefficiency and autonomic dysfunction. The nature and impact of dysautonomia are further discussed in relation to postural orthostatic tachycardia syndrome, fatigue and treatment strategies that aim to combat sympathetic overactivation by stimulating the vagus nerve. We then interrogate the mechanisms that underlie long COVID symptoms, with a focus on impaired oxygen delivery due to micro-clotting and disruption of cellular energy metabolism, before considering treatment strategies that indirectly or directly tackle these mechanisms. These include remote inspiratory muscle training and integrated care pathways that combine rehabilitation and drug interventions with research into long COVID healthcare access across different populations. Overall, this review showcases how physiological research reveals the changes that occur in long COVID and how different therapeutic strategies are being developed and tested to combat this condition.

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.

COVID-19 and athletes: Endurance sport and activity resilience study-CAESAR study

Background: The COVID-19 pandemic and imposed restrictions influenced athletic societies, although current knowledge about mild COVID-19 consequences on cardiopulmonary and physiologic parameters remains inconclusive. This study aimed to assess the impact of mild COVID-19 inflection on cardiopulmonary exercise test (CPET) performance among endurance athletes (EA) with varied fitness level. Materials and Methods: 49 EA (n_male = 43, n_female = 6, mean age = 39.94 ± 7.80 yr, height = 178.45 cm, weight = 76.62 kg; BMI = 24.03 kgm^-2) underwent double treadmill or cycle ergometer CPET and body analysis (BA) pre- and post-mild COVID-19 infection. Mild infection was defined as: (1) without hospitalization and (2) without prolonged health complications lasting for >14 days. Speed, power, heart rate (HR), oxygen uptake (VO₂), pulmonary ventilation, blood lactate concentration (at the anaerobic threshold (AT)), respiratory compensation point (RCP), and maximum exertion were measured before and after COVID-19 infection. Pearson's and Spearman's r correlation coefficients and Student t-test were applied to assess relationship between physiologic or exercise variables and time. Results: The anthropometric measurements did not differ significantly before and after COVID-19. There was a significant reduction in VO₂ at the AT and RCP (both p < 0.001). Pre-COVID-19 VO₂ was 34.97 ± 6.43 ml kg·min^-1, 43.88 ± 7.31 ml kg·min^-1 and 47.81 ± 7.81 ml kg·min^-1 respectively for AT, RCP and maximal and post-COVID-19 VO₂ was 32.35 ± 5.93 ml kg·min^-1, 40.49 ± 6.63 ml kg·min^-1 and 44.97 ± 7.00 ml kg·min^-1 respectively for AT, RCP and maximal. Differences of HR at AT (p < 0.001) and RCP (p < 0.001) was observed. The HR before infection was 145.08 ± 10.82 bpm for AT and 168.78 ± 9.01 bpm for RCP and HR after infection was 141.12 ± 9.99 bpm for AT and 165.14 ± 9.74 bpm for RCP. Time-adjusted measures showed significance for body fat (r = 0.46, p < 0.001), fat mass (r = 0.33, p = 0.020), cycling power at the AT (r = -0.29, p = 0.045), and HR at RCP (r = -0.30, p = 0.036). Conclusion: A mild COVID-19 infection resulted in a decrease in EA's CPET performance. The most significant changes were observed for VO₂ and HR. Medical Professionals and Training Specialists should be aware of the consequences of a mild COVID-19 infection in order to recommend optimal therapeutic methods and properly adjust the intensity of training.

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.

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.

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.

The effects of acute respiratory illness on exercise and sports performance outcomes in athletes - a systematic review by a subgroup of the IOC consensus group on "Acute respiratory illness in the athlete"

Acute respiratory infections (ARinf) are common in athletes, but their effects on exercise and sports performance remain unclear. This systematic review aimed to determine the acute (short-term) and longer-term effects of ARinf, including SARS-CoV-2 infection, on exercise and sports performance outcomes in athletes. Data sources searched included PubMed, Web of Science, and EBSCOhost, from January 1990-31 December 2021. Eligibility criteria included original research studies published in English, measuring exercise and/or sports performance outcomes in athletes/physically active/military aged 15-65years with ARinf. Information regarding the study cohort, diagnostic criteria, illness classification, and quantitative data on the effect on exercise/sports performance were extracted. Database searches identified 1707 studies. After full text screening, 17 studies were included (n = 7793). Outcomes were acute or longer-term effects on exercise (cardiovascular or pulmonary responses), or sports performance (training modifications, change in standardised point scoring systems, running biomechanics, match performance or ability to start/finish an event). There was substantial methodological heterogeneity between studies. ARinf was associated with acute decrements in sports performance outcomes (4 studies) and pulmonary function (3 studies), but minimal effects on cardiorespiratory endurance (7 studies in mild ARinf). Longer-term detrimental effects of ARinf on sports performance (6 studies) were divided. Training mileage, overall training load, standardised sports performance-dependent points and match play can be affected over time. Despite few studies, there is a trend towards impairment in acute and longer-term exercise and sports outcomes after ARinf in athletes. Future research should consider a uniform approach to explore relationships between ARinf and exercise/sports performance.

COVID-19 disease in professional football players: symptoms and impact on pulmonary function and metabolic power during matches

This study aimed at: (1) Reporting COVID-19 symptoms and duration in professional football players; (2) comparing players' pulmonary function before and after COVID-19; (3) comparing players' metabolic power (P_met ) before and after COVID-19. Thirteen male players (Age: 23.9 ± 4.0 years, V̇O_2peak : 49.7 ± 4.0 mL/kg/min) underwent a medical screening and performed a running incremental step test and a spirometry test after COVID-19. Spirometric data were compared with the ones collected at the beginning of the same season. Players' mean P_met of the 10 matches played before COVID-19 was compared with mean P_met of the 10 matches played after COVID-19. Players completed a questionnaire on COVID-19 symptoms and duration 6 months following the disease. COVID-19 positivity lasted on average 15 ± 5 days. "General fatigue" and "muscle fatigue" symptoms were reported by all players during COVID-19 and persisted for 77% (general fatigue) and 54% (muscle fatigue) of the players for 37 ± 28 and 38 ± 29 days after the disease, respectively. No significant changes in spirometric measurements were found after COVID-19, even though some impairments at the individual level were observed. Conversely, a linear mixed-effects model analysis showed a significant reduction of P_met (-4.1 ± 3.5%) following COVID-19 (t = -2.686, p < 0.05). "General fatigue" and "muscle fatigue" symptoms may persist for several weeks following COVID-19 in professional football players and should be considered for a safer return to sport. Players' capacity to compete at high intensities might be compromised after COVID-19.

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.

Perspectives on nano-nutraceuticals to manage pre and post COVID-19 infections

Optimized therapeutic bio-compounds supported by bio-acceptable nanosystems (i.e., precise nanomedicine) have ability to promote health via maintaining body structure, organ function, and controlling chronic and acute effects. Therefore, nano-nutraceuticals (designed to neutralize virus, inhibit virus bindings with receptors, and support immunity) utilization can manage COVID-19 pre/post-infection effects. To explore these approaches well, our mini-review explores optimized bio-active compounds, their ability to influence SARS-CoV-2 infection, improvement in performance supported by precise nanomedicine approach, and challenges along with prospects. Such optimized pharmacologically relevant therapeutic cargo not only affect SARS-CoV-2 but will support other organs which show functional alternation due to SARS-CoV-2 for example, neurological functions. Hence, coupling the nutraceuticals with the nano-pharmacology perspective of higher efficacy via targeted delivery action can pave a novel way for health experts to plan future research needed to manage post COVID-19 infection effect where a longer efficacy with no side-effects is a key requirement.