The risk of the new coronavirus and COVID-19 infection on an athlete’s heart could end fall sports before they begin.
On Monday, Paula Lavigne and Mark Schlabach of ESPN reported that an inflammation of heart muscle called myocarditis has been detected in at least five Big Ten Conference athletes, as well as among athletes in other conferences. The uncertainty about the long-term outcomes of athletes with myocarditis after COVID-19 has led to meetings among school presidents, chancellors and athletic directors, as well as conference commissioners and health advisory board members. On Tuesday, the Big Ten and Pac-12 conferences announced the postponement of all fall sports, including football.
An athlete with myocarditis commonly presents with shortness of breath with physical exertion, chest pain, and heartbeat irregularities. It can also present like a heart attack with sudden death. And myocarditis can lead to sudden death without the athlete showing symptoms ahead of time.
Unfortunately, there is much we don't know about the connection between the coronavirus and myocarditis. We have limited data of how common people who are not hospitalized with COVID-19 have cardiac injury from the virus or the long-term outcomes of that heart damage the infection can cause.
In a July study published in JAMA Cardiology, researchers used cardiovascular MRI to study the hearts of patients who had recently recovered from COVID-19. They found 60 percent had myocardial inflammation. But the median age of patients in that study was 49, not the 14- to 21-year-olds who play high school and college sports.
If an athlete develops myocarditis, whether from COVID-19 or some other virus, the guidelines for his or her return to sports are fairly straightforward. The American Heart Association and American College of Cardiology recommend that the athlete should undergo a number of tests of heart function no sooner than 3 to 6 months after a diagnosis of myocarditis, and he or she cannot return to sports until those tests are normal.
The more difficult question pertains to how to best identify myocarditis in COVID-19-positive athletes with no shortness of breath, chest pain, or heart arrhythmias. In May, members of the American College of Cardiology’s Sports & Exercise Cardiology Council issued guidelines for these athletes.
Athletes who test positive for COVID-19 but who show no symptoms from the virus should refrain from exercise and sports training for at least two weeks from the date of positive test results.
Athletes who test positive for COVID-19 who develop mild or moderate symptoms should stop all exercise and sports training for a minimum of two weeks after the symptoms completely resolve. The guidelines also recommend these athletes undergo cardiovascular testing. Only when the athlete has no symptoms and the tests show no cardiac involvement should he or she return to training.
Some Power Five schools are taking extreme measures in evaluating the heart risks for COVID-19 athletes. For example, doctors for the University of Washington teams are not just screening for heart symptoms, but they are obtaining electrocardiograms, heart ultrasounds, and measuring blood levels for proteins that show heart injury. In some cases, they have the athlete undergo a cardiac MRI.
Clemson coach Dabo Swinney was asked Monday if Clemson's medical team had been screening the players who had tested positive for the virus for cardiac issues.
"Absolutely," he said. "These guys have tremendous care. Nobody's being put on the field, or anything like that, unless they are fully cleared."
South Carolina athletics director Ray Tanner on Tuesday was asked about testing procedures.
"We are very thorough. We’re doing the PCR testing, the antigen testing, the antibody testing. If we get a positive back, we do the EKG as well, which is not the case across the country. We do that.
"The SEC, if we’re able to move forward, we’ll all be doing the same testing, every week."
One wonders whether smaller colleges and universities, or high schools, have the resources to thoroughly screen COVID-19 athletes for myocarditis. The uncertainty of the long-term effects of heart injury and the complexity of determining which athletes are at risk might be enough to stop all fall sports.
Dr. David Geier is an orthopedic surgeon in Charleston and author of “That’s Gotta Hurt: The Injuries That Changed Sports Forever.”