In the almost three years since the COVID-19 pandemic swept across the world we have seen numerous variants of the virus come and go. With each successive set of mutations, this wily adversary has gained the ability to become significantly more transmissible while often sacrificing much of the lethality that it exhibited in its earlier forms.
Although most of us would like to put the pandemic behind us, the reality is that COVID is here to stay in some form or another, and we are all going to have to learn to navigate a landscape in which recurrent infection by variants of this virus are inevitable and dishearteningly frequent.
Aside from just the inconvenience of being ill for several days, COVID still carries with it a higher chance of morbidity and mortality than other respiratory illnesses, and for athletes in particular, one of the risks of infection that carries with it the most serious consequences is myocarditis or inflammation of the heart.
Your Heart And COVID
Cardiologists have known since early in the pandemic that the virus responsible for COVID has widespread effects in the body and that even in mild infections, the cardiovascular system is prone to silent infection and long-term consequences. While those with the most severe infections tended to be the ones with the highest risk of clinical cardiac issues, studies of active adults have shown that even in mild or asymptomatic infections as many as sixty percent demonstrate signs of myocarditis when evaluated by the most sensitive test, a cardiac MRI.
Because myocarditis is known to be a risk factor for sudden cardiac death (SCD) during exercise, these alarming findings guided the very cautious return-to-play protocols that were developed in 2021, in which people were advised to take as much as four months off from exercise to mitigate the risk of SCD after COVID infection.
Since that time, a few things have come to pass that have resulted in some revision of those conservative return-to-play guidelines. First, there has been an evolution of the virus itself with milder and milder variants emerging that seem to cause less serious illness, raising the question of whether the incidence of myocarditis might also be lower.
Second, in the year or so since the guidelines were first published, there has been no epidemic of SCD among COVID survivors. This raises two distinct possibilities:
- The incidence of myocarditis in COVID survivors has either decreased dramatically or was significantly over-reported in the first place or
- The presence of myocarditis from COVID-19 is simply not as clinically significant as feared and is not as much of a risk factor for SCD as would have been predicted.
A recent article published in the Clinical Journal of Sports Medicine lends credence to the notion that myocarditis may have been vastly overstated as a concern amongst people who have mild infections. The article reports on a cohort of 65 Division 1 athletes returning to school in the fall of 2020 during which the Delta variant would have been the predominant strain of COVID infecting people in the United States.
All of the athletes had documented cases of COVID-19 and underwent cardiac testing consisting of an electrocardiogram, blood tests for serum markers of cardiac injury, and echocardiogram. If indicated, cardiac MRI was also undertaken, though this ended up only being necessary for one athlete.
Based on symptom reporting, none of the 65 had experienced more than a mild bout of COVID and many had been asymptomatic. None needed oxygen or hospitalization. All, including the one athlete who underwent cardiac MRI, had completely normal cardiac workups, and all underwent surveillance for nine months during which no adverse events of any kind were observed.
While this is a small number of athletes and while all of them were young and performing at the highest level of their respective sports, the study is still reassuring for all of us. The Delta variant was a more virulent strain of COVID-19 than the Omicron variant that now dominates the world scene and is responsible for almost all infections. If the Delta variant was not causing any myocarditis in these athletes, then it is likely that the Omicron variant is also not causing any.
More importantly, the authors of this paper take their results as positive reinforcement of the more liberal return to play guidelines that are now being used to guide all athletes at all levels for return to play: “Guidelines for adult athletes who have recovered from COVID-19 and who were asymptomatic or had only mild symptoms advise a gradual return to play without cardiac workup. Electrocardiogram, serum markers of cardiac injury, and echocardiographic testing are recommended in patients with moderate symptoms (defined as systemic symptoms including fever and/or cardiovascular symptoms). The findings in our study, including the lack of cardiac complications after return to competition, support these guidelines.”
I would add to this that anyone with a history of cardiac disease or who develops symptoms during their gradual return to play or who finds the gradual return to play more difficult than anticipated should also seek cardiac evaluation before progressing.
Still, the take home message from this paper may well be that even though COVID remains here for the long haul, the threat of post-COVID myocarditis at least, may be something we can spend less time worrying about.