Return to Play After COVID-19 Infection: A Sports Cardiology Perspective

A couple months ago, the American College of Cardiology’s (ACC) Sports and Exercise Cardiology Section endorsed a viewpoint article published in JAMA Cardiology on resumption of sports play and exercise after COVID-19 infection. Michael Emery, MD, the new Co-Director of Cleveland Clinic’s Sports Cardiology Center, contributed to the document.

In preparation for return-to-play decisions as the fall sports season approaches, Dr. Emery sat down with Tamanna Singh, MD, his fellow Co-Director of the Sports Cardiology Center, to discuss the document and related issues in an episode of Cleveland Clinic’s Cardiac Consult podcast. Read on for an edited transcript of key portions of the discussion.

Dr. Singh: Dr. Emery, can you share some essentials about the new ACC-endorsed statement on return to play after COVID-19 infection?

Dr. Emery: I’d start by pointing out that the statement presents guidelines, not mandates, and that they’re based on expert opinion, not driven by data, which we don’t have a lot of at this time, particularly among athletes.

Much of the data is driven by what we see in the inpatient realm, where there seems to be a higher prevalence of cardiac involvement with this virus than with other viruses. That has given rise to concern about athletes who may be exercising intensely, particularly in the setting of having active COVID-19 or even just mild symptoms. We were quite concerned that there could be a higher prevalence of cardiac involvement, even in the outpatient setting, with this disease state than with other respiratory viral infections, such as the flu or common cold.

We were very conservative in regard to our recommendations. Those start with the asymptomatic athlete who tests positive for COVID-19, which is something we’re seeing more often as many university systems are now screening all their athletes and some may test positive but not have symptoms. For the asymptomatic athlete, we recommended just rest for two weeks. That correlates with a two-week period of isolation and quarantine that we’d want to have anyway, but it also may help address the concern that exercising intensely in the setting of a viral infection may increase the risk for myocardial involvement, even in the absence of symptoms. That’s a concern that’s been raised by some animal data.

For COVID-19-infected athletes with any degree of symptoms, we recommended some additional cardiac testing, once they have completely recovered, that goes beyond what we would typically do in the setting of flu or another respiratory viral infection where there’s not concern about myocardial involvement. Specific recommendations are outlined in an algorithm within the published document outlining what to do, particularly for high-intensity athletes and university or professional athletes.

Dr. Singh: To me, one of the key points is the importance of cardiologists using our clinical gestalt, in addition to these recommendations, when evaluating athletes in clinic. That’s what I have been doing, particularly with collegiate athletes who are trying to maintain some level of conditioning and exercise as they await return to play on campus. Additionally, these recommendations have been helpful when I evaluate recreational masters athletes who are concerned about their exposure to the virus and have had symptoms that may be suggestive of COVID-19. I have used some of these recommendations when discussing whether or not they can return to play or return to their usual recreational activities.

Dr. Emery: It’s worth repeating that these are guidelines, not mandates. Clinical gestalt is important. If there’s concern for cardiac involvement, you are going to push more aggressively looking for it, which may drive how extensively you do cardiac testing.

In the document, we recommended a slow return after an athlete has recovered. That is predicated in part on the fact that the athlete was taken out of training for two weeks and may have been totally sedentary and detrained. So the ideas is to avoid throwing them right back in with the rest of the team who have been training all along. You really need to start them slow, realizing they just detrained.

Dr. Singh: That’s a great point. Another issue we’ll be seeing as we roll into the early fall is returning to campuses or to seasonal sports and having to discuss what to do with pre-participation screening. Here at Cleveland Clinic, that’s something we’re working on in close collaboration with our sports medicine physicians, our team physicians for local colleges and the team physicians for our affiliated professional sports teams.

Dr. Emery: Clear communication with our primary care sports medicine colleagues is super important in these situations. This is a scary time with many unknowns. A lot of our sports medicine colleagues are just trying to get their athletes back on campus or back into their facilities, so it’s helpful if we can take some of the concern about cardiac involvement off their plate.

Dr. Singh: Absolutely. And while we hope this pandemic is not something we’ll need to contend with too far into the future, I think it does give us some leverage with regard to creating an algorithm so that if we do encounter a similar situation, we’ll be more prepared to address it head-on.

Dr. Emery: Yes, and it also provides the opportunity to collect data we don’t have on other viral infections so that, in the future, we can actually have data driving these recommendations and rely a bit less on expert opinion.

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