College Athletes Are at Low Risk of Cardiac Involvement From Mild COVID-19

Return to sport without cardiac testing reasonable after recovery, registry study suggests

SARS-CoV-2 viral infection in college athletes is unlikely to involve the heart, leading to a very low risk of cardiac events. This finding, from the largest study to date of athletes with COVID-19, supports guidance that those who recover from an asymptomatic or mild course may resume sports without cardiac testing. The study report, published online in Circulation, recommends considering cardiac evaluation only for athletes with at least moderate COVID-19 disease or who have cardiopulmonary symptoms.

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“Our findings put SARS-CoV-2 in line with other viruses in terms of risk of cardiac involvement in college athletes following a mild infection,” says Michael Emery, MD, Co-Director of Cleveland Clinic’s Sports Cardiology Center and a member of the steering committee for the registry used in the study. “Physicians and coaches can be reassured that advising athletes to return to play after recovery without cardiac testing is reasonable.”

Cardiac concerns in athletes

Because myocarditis following viral infections is a well-documented cause of sudden death in athletes, some organized sports events have been cancelled out of concern for this possibility with COVID-19. Although SARS-CoV-2 infection was found to result in high rates of indicators of cardiac involvement in middle-aged patients hospitalized with COVID-19, whether this is the case with young athletes had not been determined.

To help answer this question, the national Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) was established to collect COVID-19 outcomes data from National Collegiate Athletic Association (NCAA) athletes.

Study design and findings

The investigation was a prospective observational cohort study with ORCCA data from 42 colleges and universities. Nearly 20,000 athletes were tested for SARS-CoV-2 infection, with 3,018 testing positive and meeting inclusion criteria (mean age, 20 years; 32% female); the majority were asymptomatic (33%) or mildly symptomatic (29%). Of these 3,018 athletes, 93% underwent at least one of the following triad of cardiac tests:

  • 12-lead ECG, which showed abnormal findings in 0.7% (21/2,999)
  • Cardiac troponin testing, which yielded abnormal findings in 0.9% (24/2,719)
  • Transthoracic echocardiography (TTE), which revealed abnormal findings in 0.9% (24/2,556)

Clinically indicated cardiac magnetic resonance imaging (CMR) was performed on 119 athletes, either because of a borderline or abnormal triad test result or because they experienced moderate symptoms, while primary screening with CMR was performed on 198 athletes who tested positive for SARS-CoV-2.

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SARS-COV-2 cardiac involvement was identified in 21 of the 3,018 athletes (0.7%) who tested positive and was considered definite or probable in 15 (0.5%) and possible in 6 (0.2%). This included 15 of 2,820 athletes (0.5%) who underwent clinically indicated CMR (n = 119) and 6 of 198 (3.0%) who underwent primary screening CMR.

Cardiac involvement was best predicted by the presence of either of the following:

  • Cardiopulmonary symptoms (odds ratio = 3.1; 95% CI, 1.2-7.7)
  • At least one abnormal triad test (odds ratio = 37.4; 95% CI, 13.3-105.3)

No adverse cardiac events were reported over a median follow-up of 130 days in athletes deemed to have definite, probable or possible SARS-COV-2 cardiac involvement. Five athletes (0.2%) required hospitalization, in all cases for noncardiac complications.

Selective testing recommended

Dr. Emery notes that because sudden death due to post-viral myocarditis is preventable if the condition is detected early, many team doctors were screening every athlete with CMR after a COVID-19 infection. This study provides evidence that this costly and time-consuming strategy is unnecessary, he says.

He highlights the following key takeaways from the results:

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  • Prevalence of cardiac involvement in SARS-CoV-2 infection among young athletes is very low.
  • CMR is most useful in athletes with a high pretest probability of cardiac involvement. Factors that should trigger consideration of CMR are the presence of any abnormal triad test result or cardiopulmonary symptoms.
  • Asymptomatic or mildly symptomatic athletes can return to sports under proper supervision without cardiac testing after full recovery from COVID-19, consistent with published guidelines from the American College of Cardiology and American Medical Society for Sports Medicine.

“This is an important study that is reassuring for patients and clinicians,” notes Leslie Cho, MD, Co-Section Head of Preventive Cardiology at Cleveland Clinic, who wasn’t involved in the study. “Symptoms and abnormal testing should guide who gets cardiac MRI.”

Next steps

ORCCA is collecting more data, which Dr. Emery says will continue to help set best practices for college athletes. While this study followed athletes for a median of 130 days, additional longitudinal data will allow detection of any post-acute sequelae that may arise. In addition, data are being collected for cardiovascular disease unrelated to COVID-19.

“We have an excellent system in place for detecting events at colleges and universities across the country,” says Dr. Emery. “ORCCA will build on the momentum of this study for COVID-19 and beyond.”