Preparticipation cardiovascular screening (PPCS), designed to identify cardiovascular pathology responsible for sudden unexpected death, is recommended by all major medical practice oversight organizations overseeing the clinical care of competitive athletes. PPCS involves ascertainment of a personal and family past medical history, focused physical examination, and consideration of the use of 12-lead electrocardiography. Concerns about COVID-19 cardiovascular complications, specifically myocarditis, led to testing considerations above and beyond routine PPCS, including transthoracic echocardiography and blood troponin measurement prior to a return to play (RTP) following COVID-19 infection. Data from several large, prospective, cohort studies indicate that cardiac imaging findings consistent with inflammatory heart disease following COVID-19 infection are more common than most forms of heart disease associated with sudden death during exercise. However, the clinical significance of cardiac imaging abnormalities after COVID-19 infection in the absence of clinical symptoms of myocarditis remains incompletely understood.
While selection of athletes for RTP testing following COVID-19 infection has become a focus, routine PPCS, which has the capacity to detect cardiovascular complications associated with COVID-19, other infections, and pathology unrelated to infection, remains of paramount importance during the pandemic. This document is intended to provide recommendations about how routine PPCS for young competitive athletes, a group that includes any athlete eligible for PPCS including those participating at high school, collegiate, and elite levels of sport, should be altered to account for recent scientific advances.
Routine PPCS in the Era of COVID-19
PPCS is one of several key components of a comprehensive preparticipation physical evaluation (PPE) strategy (1). The 2019 Preparticipation Physical Evaluation, 5th edition monograph (PPE5) (2), the most widely applied PPE tool, is based on four fundamental principles: 1) determining the general physical and psychological health of the athlete; 2) evaluating for the presence of possible life-threatening or disabling conditions; 3) evaluating for conditions predisposing to possible injury or illness; and 4) serving as an entry point into the health care system for student athletes without an established medical home. Accordingly, a fundamental goal of the PPE5 and similar more focused PPCS tools (3), is to evaluate for congenital, genetic, and acquired cardiovascular disorders associated with sudden cardiac arrest during exercise. As high-risk cardiovascular disorders require detection regardless of whether or not they are attributable to COVID-19, this objective has remained unchanged during the COVID-19 pandemic (4).
Among athletes with limited resources and access to health care, routine PPE often serves as their only medical encounter. However, mandatory PPE also may be a barrier to sports participation when resources required to perform PPE and to conduct timely downstream testing are limited. COVID-19 has magnified the inequities inherent in sport participation and impeded access to medical and psychological care especially for vulnerable populations and unnecessary cardiac testing following COVID-19 infection may be an additional barrier to clearance for socioeconomically or medically disadvantaged athletes. During the pandemic, free play, organized practices, and competitions all declined significantly as sports became less accessible. Athletes from lower income communities were disproportionately affected, spending less than 2 h·wk−1 in play than higher income youth and White youth athletes returned to organized athletic competitions faster than Asian, Hispanic/Latino, and Black youth athletes (5). In addition, the impact of COVID-19 on youth athlete mental health — measured by quality of life as defined by physical, psychosocial, and overall health — appears to be worse among athletes from areas with the highest poverty levels (6).
Cardiovascular Sequalae of COVID-19 Infection
Inflammatory heart disease, specifically postviral myocarditis (7), is a well-established cause of sudden death during exercise (8). Prepandemic expert consensus guidelines — with a goal of reducing malignant ventricular arrhythmias during active cardiac inflammation — recommend a 3- to 6-month period of sport restriction for competitive athletes diagnosed with myocarditis (9). Early in the COVID-19 pandemic, reports of cardiac injury among hospitalized patients led to concerns about the safety of sport following infection (10). These concerns provided the rationale for subsequent studies examining cardiovascular sequelae of COVID-19 infection among competitive athletes and for the generation of RTP testing recommendations following infection (11).
Early single-center studies of athletes utilized cardiac magnetic resonance imaging (CMRI) to screen all athletes recovering from COVID-19 and reported a wide range of CMRI abnormalities of unknown significance (up to 56% of athletes) with rates of myocarditis ranging between 2% and 15% (12,13). An important limitation of these initial studies was that the diagnosis of inflammatory heart disease was based on CMRI alone without consideration of the clinical features typically used to establish ischemic heart disease (IHD) (e.g., symptoms suggestive of inflammatory heart disease, elevation in blood troponin levels). Subsequently, multicenter studies from National Collegiate Athletic Association (NCAA) universities and professional sports organizations reported a substantially lower prevalence estimates (0.5% to 3%) of clinically relevant COVID-19 cardiac involvement (14,15). Disease detection in these large cohorts relied largely on stepwise RTP testing that integrates the results of symptom screening, electrocardiography, echocardiography, and cardiac troponin testing to determine the need for CMRI rather than screening all athletes with this imaging modality. The contrasting results from these two approaches to screening raised concern about the impact of a failure to detect subtle forms of inflammatory heart disease that may only be revealed by routine application of CMRI in all athletes. However, on-going clinical surveillance of the athlete cohorts screened using a stepwise approach reveal a near complete absence of adverse cardiovascular events related to COVID-19 (14). This reassuring finding suggests that subclinical inflammatory heart disease appears to be of limited concern and that activity restriction in confirmed cases of inflammatory heart disease successfully reduces adverse events.
Expert consensus recommendations delineating the RTP evaluation after COVID-19 have evolved in parallel with increasing clinical experience and emerging data (16,17). Current recommendations suggest characterization of COVID-19 symptoms — particularly the identification of severe acute systemic illness and/or the presence cardiovascular symptoms during acute infection and/or return to exercise — to determine the necessity of cardiac testing during postinfectious RTP evaluations. This approach emphasizes the role of establishing the pretest probability of disease to restrict costly testing to the small percentage of athletes most likely at risk for inflammatory heart disease (18). As delineated below, this conservative approach to disease detection provides a practical platform — consistent with common practice in preventive medicine — for reappraisal of the PPCS in the era of COVID-19.
Postacute Sequelae of SARS-CoV-2
Although not consistently defined in clinical practice or in the scientific literature, postacute sequelae of COVID-19 (PASC; “long COVID”) refers to symptoms persisting weeks to months after acute infection. Studies in the general population suggest alarming rates of PASC. A recent systematic review, including 57 studies with 250,351 survivors of COVID-19, reported a 54% prevalence of persistent symptoms at 6 months (19). This cohort was comprised of older individuals (54 ± 8.9 years) among whom 79% had been hospitalized for COVID-19 and is not representative of young competitive athletes undergoing PPCS. However, small studies examining nonhospitalized young adults (>16 years) in the general population also have shown high rates of PASC (35% to 52%) (20,21). In contrast, a recent study of 3527 collegiate athletes reported a PASC prevalence of less than 1% at 3 months following acute infection (22). This discrepancy is likely explained by the comparatively greater physical fitness — a characteristic associated with less severe acute outcomes from SARS-CoV-2 infection (23) — and a substantially lower burden of medical comorbidities among collegiate athletes compared with the general population. Nonetheless, PPCS provides an ideal opportunity to assess for PASC and to educate athletes about the importance of reporting any new or persistent symptoms — particularly exertional chest pain — which may manifest during sports participation.
Reappraisal of PPCS in the Era of COVID
While inflammatory heart disease secondary to COVID-19 appears to be less common among young competitive athletes than predicted early in the pandemic, established prevalence estimates suggest that cardiac imaging abnormalities suggestive of inflammatory heart disease are more common than all other forms of cardiovascular disease associated with sudden death during exercise (14). In addition, postinfectious inflammatory heart disease triggered by alternative pathogens also remains clinically relevant during the COVID-19 pandemic. Importantly, experimental animal models demonstrate an increased risk of adverse events attributable to postinfectious inflammatory heart disease in the setting of vigorous physical activity (24). Therefore, this writing group suggests modifying routine PPCS standards to address several key issues related to postinfectious IHD. A simple algorithm easily incorporated into all preexisting PPCS tools is presented in the Figure.
Key recommendations are summarized as follows. First, PPCS should include a history of recent infectious illnesses, including COVID-19 infection, focusing on symptom severity and the presence of cardiovascular symptoms (dyspnea, palpitations, and chest pain, pressure, or tightness). These historical elements of the PPCS inform pretest probability of postinfectious inflammatory heart disease (18). Second, for athletes who have returned to exercise, it is critical to confirm they feel well and to exclude the presence of exertional cardiovascular symptoms. The PPCS should identify prolonged or newly emerging symptoms following acute infection, specifically exertional chest pain, as this has been identified as a common feature among athletes with postinfectious inflammatory heart disease (22). Third, PPCS provides an opportunity to determine athlete vaccination status and to educate about and facilitate vaccination administration (25). Fourth, PPCS should include athlete education regarding the importance of reporting new onset cardiovascular symptoms during exercise following infection including but not limited to COVID-19. Finally, a comprehensive preparticipation physical evaluation provides a valuable opportunity to screen for anxiety, depression, and suicidal ideation possibly caused by, or exacerbated by, the COVID-19 pandemic. These proposed modifications were designed for use during routine PPCS, but they also may facilitate the COVID-19 RTP assessment as a platform for the succinct ascertainment of infection and recovery history. While it is anticipated that this algorithm will lead to enhanced disease detection both during and after the current pandemic, data-driven clarification of its impact on PPCS performance represents an important area of future study.
The authors declare no conflict of interest and do not have any financial disclosures.
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