In a recent article published in the journal Heart, researchers evaluated the long-term effects of resuming elite sports on cardiac health after recovering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
Athletes are prone to sports-induced cardiac effects; at the same time, maintaining cardiac integrity is a prerequisite for delivering high-end performance.
Study: Long-term cardiac follow-up of athletes infected with SARS-CoV-2 after resumption of elite-level sports. Image Credit: Jacob Lund / Shutterstock
In-human studies during active myocarditis are lacking due to ethical reasons. However, studies in mice have shown that strenuous physical activity, e.g., elite sports, could lead to severe cardiac effects, including ventricular tachyarrhythmias and mortality.
Accordingly, clinicians refrain athletes diagnosed with active myocarditis from sports, which might adversely impact their professional careers. In fact, active myocarditis is considered an absolute contraindication for participation in sports.
Since studies have implicated myocarditis in COVID-19 cases among young athletes, examining the long-term effects of playing sports after recovering from coronavirus disease 2019 (COVID-19) is highly clinically relevant.
However, cross-sectional studies mainly focused on the prevalence of cardiac aberrations and implemented return-to-sports (RTS) screening protocols, and prospective studies investigating longer-term outcomes of sports participation on cardiac health post-COVID-19 are lacking.
About the study
In the present prospective controlled study, researchers recruited Olympians, Paralympians, and other professional athletes from the Evaluation of Lifetime Participation in Intensive Top-level Sports and Exercise (ELITE) longitudinal cohort who were ≥16 years old, with an exercise routine of ≥10 h/week for competing in high-end sports.
Next, they subjected athletes with confirmed COVID-19 from the ELITE cohort to structured cardiovascular screenings, including electrocardiography (ECG), laboratory assessments, and cardiovascular magnetic resonance (CMR). These athletes constituted 'COVID-19 Myocardial Manifestations in Intensive Top-level Sports and Exercise' (COMMIT), a subcohort of the ELITE study.
First, the team compared ventricular volumes and function, late gadolinium enhancement (LGE), and native T1 relaxation times of SARS-CoV-2-infected and non-infected ELITE athletes. Further, they examined long-term detrimental cardiac effects, including cardiac adverse events and ventricular arrhythmia burden, to determine whether SARS-CoV-2 infection led to the cessation of their sports careers.
In addition, when the CMR of a SARS-CoV-2-infected athlete demonstrated cardiac abnormalities, the team repeated CMR evaluations at three, six-, and nine months post-infection. The researchers also collected each participant's age, gender, ethnicity (sociodemographic data), athletic discipline, and the time spent playing professional-level sports.
Of 259 athletes recruited for COMMIT, 123 recovered from a SARS-CoV-2 infection, and 136 comprised the non-infected control group. SARS-CoV-2-infected athletes were younger and less likely to be of Caucasian ethnicity; moreover, 9% and 72% had cardiovascular and respiratory symptoms, respectively. These infected individuals also had higher resting heart rates; however, their cardiac and inflammatory markers and ECG categories were comparable to controls.
Based on pre- and post-infection CMR results, SARS-CoV-2 infection showed no detrimental effects on volumetric and functional CMR parameters of all athletes who resumed elite sports. Prevalence of perimyocardial involvement (SARS-CoV-2 cardiac sequelae) was extremely low (3%), with a temporally variable clinical presentation and course.
Only four SARS-CoV-2-infected athletes demonstrated pathological non-ischaemic patterns of myocardial LGE, with some athletes showing complete resolution of LGE, while others had persistent LGE but no signs of inflammation.
Even in ELITE athletes with cardiac sequelae who resumed competitive sports, damaging morphological alterations or ventricular arrhythmias were absent. Moreover, the authors noted no new de novo or adverse cardiac events in athletes over two years of follow-up, regardless of SARS-CoV-2-triggered cardiac issues at the baseline post-infection assessment.
Athletes who participate in elite sports constitute a distinctive phenotype to investigate the role of physical activity as a trigger for adverse cardiac remodeling post-COVID-19.
Consistent with previous findings, the present study showed that post-COVID-19 myocardial injury was low in athletes during the 26.7 months (long-term) study follow-up. More importantly, a prior SARS-CoV-2 infection did not lead to the cessation of a professional athletic career, regardless of the presence/absence of cardiac sequelae.
A reduction in the left-ventricular remodeling index in individuals with pre- and post-COVID-19 CMR measurements showed the effect of detraining during the COVID-19 pandemic; however, COVID-19 did not cause detrimental ventricular volumetric and functional changes.
Overall, successful RTS is achievable, even for athletes with myocardial abnormalities, albeit with appropriate counseling during return-to-sports trajectories. The study data could also help devise evidence-based protocols for safe RTS after SARS-CoV-2 infection for all athletes.