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

Long-term manifestations of COVID-19 in athletes: a narrative review

BACKGROUND

Long COVID is a condition where symptoms or complications persist beyond 3 months after COVID-19 infection. Although most athletes experience mild symptoms, those involved in sports with higher cardiovascular demands can develop long COVID, which can negatively impact sports performance. This narrative review aimed to analyze the long COVID in athletes, especially cardiovascular effects; to alert medical and sporting community for the clinical aftermaths of COVID-19, focusing on physical activity; and to discuss the potential return-to-play strategies for these athletes.

METHODS

An electronic search in PubMed database for articles published between January/2020 and February/2023 was performed including athletic populations with COVID-19, emphasizing long-term complications, especially the cardiovascular effects.

RESULTS AND CONCLUSIONS

While severe cardiac complications are rare, athletes with long COVID often experience symptoms such as fatigue, dyspnea, palpitations, and exercise intolerance. To manage athletes with long COVID, individualized and structured return-to-play programs with the involvement of multidisciplinary teams are crucial. This underscores the importance of recognizing long COVID in athletes, raising awareness of its potential impacts, and implementing strategies to ensure a safe return to play.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Aim

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

Methods

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

Results

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

Conclusions

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

The Influence of Different SARS-CoV-2 Strains on Changes in Maximal Oxygen Consumption, Ventilatory Efficiency and Oxygen Pulse of Elite Athletes

PURPOSE

The aim of this study was to evaluate the influence of different SARS-CoV-2 strains on the functional capacity of athletes.

METHODS

In total, 220 athletes underwent cardiopulmonary exercise testing (CPET) after coronavirus infection and before returning to sports activities. Eighty-eight athletes were infected by the Wuhan virus, and 66 were infected during the Delta and Omicron strain periods of the pandemic.

RESULTS

The CPET results showed significantly decreased maximal oxygen consumption, ventilatory efficiency, and oxygen pulse in athletes who were infected with Wuhan and Delta strains compared to athletes who suffered from Omicron virus infection. An early transition from aerobic to anaerobic metabolic pathways for energy production was observed in the Wuhan and Delta groups but not in athletes who were infected with the Omicron strain. There were no differences in the obtained results when Wuhan and Delta virus variants were compared.

CONCLUSION

These results suggest that the Wuhan and Delta virus strains had a significantly greater negative impact on the functional abilities of athletes compared to the Omicron virus variant, especially in terms of aerobic capacity and cardiorespiratory function.

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.

How Different Predominant SARS-CoV-2 Variants of Concern Affected Clinical Patterns and Performances of Infected Professional Players during Two Soccer Seasons: An Observational Study from Split, Croatia

There are limited data describing clinical patterns and match running performance (MRP) among players with COVID-19 infection before and after infection, particularly related to different predominant SARS-CoV-2 variants, as well as in comparison to uninfected players. This observational study was conducted during two consecutive soccer seasons in one professional club in Split, Croatia. There were four clusters of mild, self-limited, or asymptomatic infection characterised by low adherence to preventive measures. Infected players had significantly more symptoms (t-test = 3.24; p = 0.002), a longer period of physical inactivity (χ² = 10.000; p = 0.006) and a longer period of self-assessment for achieving full fitness (χ² = 6.744; p = 0.034) in the 2020-2021 season (Wuhan wild strain and Alpha variant) than in the 2021-2022 season (Omicron variant). It was also found that, despite the milder clinical presentation of the infection in the 2021-2022 season, the players had significantly more abnormal laboratory findings (χ² = 9.069240; p = 0.002), although without clinical significance at the time of the study. As for the MRP, player performance in the 2021-2022 season was not negatively affected by the Omicron variant, while there was an improvement in MRP in scores for a sample of all players. The RTP protocol was correctly applied because it helped the athletes to recover their pre-infection physical capacities relatively quickly. This study advances the understanding that an optimally and individually planned RTP protocol is crucial for the MRP of infected players. Future research needs to replicate the findings of abnormal laboratory results and extend the study focusing on their potential long-term clinical significance.

A Case Series of SARS-CoV-2 Reinfection in Elite Athletes

OBJECTIVES

The actual frequency and the risk factors of SARS-CoV-2 reinfection is still a matter of intense scientific discussion. In this case series, we report three elite athletes who underwent COVID-19 reinfection with a short time frame.

CASE PRESENTATIONS

As a part of contact tracing, three speed skaters (22-, 24-, and 29-year-old males) were found to be SARS-CoV-2 positive by polymerase chain reaction (PCR) tests. Later on, only one of the athletes experienced mild symptoms, such as fatigue, loss of smell and taste and subfebrility, while the other two athletes were asymptomatic. Following the quarantine period, detailed return-to-play examinations, including laboratory testing, ECG, 24-h Holter monitoring, transthoracic echocardiography and cardiac magnetic resonance imaging, revealed no apparent abnormality; therefore, the athletes restarted training. After a median of 74 days, all three athletes presented with typical symptoms of COVID-19, such as fever, marked fatigue and headache. SARS-CoV-2 PCR tests were performed again, showing recurrent positivity. Repeated return-to-play assessments were initiated, finding no relevant abnormality. Athletes were also tested for SARS-CoV-2 anti-nucleoprotein antibody titers, showing only modest increases following the second infection.

CONCLUSIONS

We report a small cluster of elite athletes who underwent a PCR-proven SARS-CoV-2 reinfection. According to these findings, athletes may be considered as a high-risk group in terms of recurrent COVID-19.