COVID-19: the Risk to Athletes

Image Timing After COVID-19 Infection in Athletes

BACKGROUND

Coronavirus disease 2019 (COVID-19) has significantly impacted National Collegiate Athletic Association (NCAA) athletics, with specific concerns for cardiac involvement after infection. Pericardial abnormalities have been seen in up to 39.5% of athletes after COVID-19 infection, while myocardial involvement has been reported at a lower rate of 2.7%. To date, myocardial injury has been seen in 0.6% to 0.7% of athletes when using symptom screening and imaging as clinically indicated, which increases to 2.3% to 3.0% when all athletes with COVID-19 undergo cardiac magnetic resonance (CMR) imaging.

PURPOSE

This study will examine whether there exists an ideal time from positive COVID-19 results to obtaining imaging to increase the likelihood of finding abnormalities.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

NCAA athletes at West Virginia University who were found to be COVID-19 positive on routine screening were required to undergo echocardiography (ECG) and CMR. These data were reviewed by cardiology and determined to be normal or abnormal. Statistical analysis with logistic regression and descriptive statistics was performed to evaluate whether a time existed where abnormalities on imaging were most likely to be found.

RESULTS

A total of 41 athletes were included in this study. ECG was performed earlier on average than CMR imaging, at 18.2 days versus 27.5 days. No significant difference was found in timing from COVID-19 infection diagnosis and abnormalities seen on imaging for either ECG or CMR imaging.

CONCLUSION

The risk of cardiac involvement in athletes in the setting of COVID-19 has already been documented. This study suggests that imaging timing is independent of cardiac involvement with no correlation to specific time periods where more abnormalities may be found. However, CMR imaging showing changes at day 54 after infection suggests cardiac findings can be seen months after imaging.

CLINICAL RELEVANCE

Cardiac imaging for athletes after contracting COVID-19 does not show a significant relationship to time of imaging. However, given the cardiac involvement seen months after diagnosis, further examination of prolonged cardiac effects must be carried out.

Impaired Cardiorespiratory Fitness of Elite Athletes after Asymptomatic or Mild SARS-CoV-2 Infection

Background and Objectives: The aim of the study was to evaluate the health status of professional athletes after recovering from COVID-19 and the impact that SARS-CoV-2 had on their overall cardiorespiratory fitness, which was done by conducting cardiopulmonary exercise testing (CPET). Materials and Methods: A total of twenty-seven professional basketball players (Euroleague Basketball and the ABA League) participated in the study. CPET was performed before (as part of their regular preparticipation exam, during the pre-season period), as well as after SARS-CoV-2 infection (after two weeks of home isolation, during the competitive part of the season). CPET was performed on a treadmill, while cardiovascular, respiratory, and metabolic functions were evaluated by using a breath-by-breath analysis technique (Quark CPET system manufactured by Cosmed, Rome, Italy). Results: Maximal oxygen consumption and aerobic efficiency were significantly reduced after SARS-CoV-2 infection (p = 0.000). An obvious decrease in oxygen pulse was observed during CPET after recovering from COVID-19 (p = 0.001), as was deterioration of ventilatory efficiency. Internal respiration was the most negatively affected. An early transition from aerobic to anaerobic mechanisms of creating energy for work and intensive metabolic fatigue were obvious after SARS-CoV-2 infection. Conclusions: Although it was believed that SARS-CoV-2 only affects the cardiopulmonary status of the elderly population and people with associated comorbidities, it is clear from this research that professional athletes can also be at certain risk. Even though no pathological cardiovascular and respiratory changes were found in athletes after COVID-19, results showed significantly decreased cardiorespiratory fitness, with an emphasis on internal respiration.

Team Approach: Diagnosis, Management, and Prevention of Sudden Cardiac Arrest in the Athlete

» Sudden cardiac events during sports competition are rare but tragic occurrences that require a timely, comprehensive response by well-prepared athletic trainers and medical providers. This sequence should prioritize prompt emergency medical system activation, immediate initiation of cardiopulmonary resuscitation (CPR), automated early defibrillation (AED), and comprehensive advanced life support efforts.» Exercise-induced cardiac remodeling, referred to as the "athlete's heart," refers to a host of adaptive changes that increase cardiac chamber size and wall thickness to allow for greater pressures and volumes during exercise. This remodeling phenotype may overlap with other inherited cardiomyopathies and cardiac abnormalities, which can complicate clinical care. The long-term implications of this electrical and structural remodeling on cardiac function are unknown.» Although the best screening strategies to optimize primary prevention of sudden cardiac arrest is an evolving topic, the effectiveness of CPR and early defibrillation use in treating out-of-hospital sudden cardiac arrest has been well-established, despite their reported underuse.

Autonomic and vascular function testing in collegiate athletes following SARS-CoV-2 infection: an exploratory study

Introduction: Recent studies suggest that SARS-CoV-2 infection alters autonomic and vascular function in young, otherwise healthy, adults. However, whether these alterations exist in young competitive athletes remains unknown. This study aimed to assess the effects of COVID-19 on cardiac autonomic control and vascular function in collegiate athletes who tested positive for COVID-19, acknowledging the limitations imposed by the early stages of the pandemic. Methods: Sixteen collegiate athletes from various sports underwent a battery of commonly used autonomic and vascular function tests (23 ± 9, range: 12-44 days post-infection). Additionally, data from 26 healthy control participants were included. Results: In response to the Valsalva maneuver, nine athletes had a reduced early phase II blood pressure response and/or reduced Valsalva ratio. A depressed respiratory sinus arrhythmia amplitude was observed in three athletes. Three athletes became presyncopal during standing and did not complete the 10-min orthostatic challenge. Brachial artery flow-mediated dilation, when allometrically scaled to account for differences in baseline diameter, was not different between athletes and controls (10.0% ± 3.5% vs. 7.1% ± 2.4%, p = 0.058). Additionally, no differences were observed between groups when FMD responses were normalized by shear rate (athletes: 0.055% ± 0.026%/s-1, controls: 0.068% ± 0.049%/s-1, p = 0.40). Discussion: Few atypical and borderline responses to autonomic function tests were observed in athletes following an acute SARS-CoV-2 infection. The most meaningful autonomic abnormality being the failure of three athletes to complete a 10-min orthostatic challenge. These findings suggest that some athletes may develop mild alterations in autonomic function in the weeks after developing COVID-19, while vascular function is not significantly impaired.

Former SARS-CoV-2 Infection Was Related to Decreased VO2 Peak and Exercise Hypertension in Athletes

The impact of former COVID-19 infection on the performance of athletes is not fully understood. We aimed to identify differences in athletes with and without former COVID-19 infections. Competitive athletes who presented for preparticipation screening between April 2020 and October 2021 were included in this study, stratified for former COVID-19 infection, and compared. Overall, 1200 athletes (mean age 21.9 ± 11.6 years; 34.3% females) were included in this study from April 2020 to October 2021. Among these, 158 (13.1%) athletes previously had COVID-19 infection. Athletes with COVID-19 infection were older (23.4 ± 7.1 vs. 21.7 ± 12.1 years, p < 0.001) and more often of male sex (87.7% vs. 64.0%, p < 0.001). While systolic/diastolic blood pressure at rest was comparable between both groups, maximum systolic (190.0 [170.0/210.0] vs. 180.0 [160.0/205.0] mmHg, p = 0.007) and diastolic blood pressure (70.0 [65.0/75.0] vs. 70.0 [60.0/75.0] mmHg, p = 0.012) during the exercise test and frequency of exercise hypertension (54.2% vs. 37.8%, p < 0.001) were higher in athletes with COVID-19 infection. While former COVID-19 infection was not independently associated with higher blood pressure at rest and maximum blood pressure during exercise, former COVID-19 infection was related to exercise hypertension (OR 2.13 [95%CI 1.39-3.28], p < 0.001). VO₂ peak was lower in athletes with compared to those without COVID-19 infection (43.4 [38.3/48.0] vs. 45.3 [39.1/50.6] mL/min/kg, p = 0.010). SARS-CoV-2 infection affected VO₂ peak negatively (OR 0.94 [95%CI 0.91-0.97], p < 0.0019). In conclusion, former COVID-19 infection in athletes was accompanied by a higher frequency of exercise hypertension and reduced VO₂ peak.

Clinical spectrum of COVID-19 complications in young adults: combined analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry and the Outcomes Registry for Cardiac Conditions in Athletes

BACKGROUND

While young adults 18-24 years old bear a significant proportion of COVID-19 diagnoses, the risk factors for hospitalisation and severe COVID-19 complications in this population are poorly understood.

OBJECTIVE

The objective of this study was to identify risk factors for hospitalisation and other COVID-19 complications across the health spectrum of young adults diagnosed with COVID-19 infection.

STUDY DESIGN

Retrospective cohort study.

PARTICIPANTS

Young adults (aged 18-24) with confirmed COVID-19 infection from the American Heart Association (AHA) COVID-19 Cardiovascular Disease Registry of hospitalised patients and the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study of collegiate athletes. The AHA registry included 636 young adults from 152 hospitals. The ORCCA registry consisted of 3653 competitive college athletes from 42 colleges and universities.

INTERVENTION

None (exposure to COVID-19).

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes included hospitalisation, death, major adverse cardiovascular events (MACE) and other severe clinical events.

RESULTS

In comparison to the ORCCA registry, patients in the AHA registry were more likely to be female (59% vs 33%); had higher average body mass index (BMI) (32.4 vs 25.6); and had increased prevalence of diabetes (10% vs 0.4%), hypertension (7% vs 0.6%), chronic kidney disease (2% vs 0%) and asthma (14% vs 8%), all with p<0.01. There were eight (2%) deaths in the AHA hospitalised registry compared with zero in the ORCCA cohort. BMI was a statistically significant predictor of death in the hospitalised cohort (OR 1.05, 95% CI 1.00, 1.10). No significant predictors of MACE or other severe clinical events were identified.

CONCLUSIONS

The risk of cardiac events in young adults aged 18-24 diagnosed with COVID-19 infection is low. Patients who were hospitalised (AHA registry) were more likely to have pre-existing medical comorbidities and higher BMI than healthy collegiate athletes (ORCCA registry). Once hospitalised, elevated BMI is associated with increased mortality although other drivers of MACE and other severe clinical events remain unclear.

The Influence of Nutrition and Physical Activity on Exercise Performance after Mild COVID-19 Infection in Endurance Athletes-CESAR Study

COVID-19 and imposed restrictions are linked with numerous health consequences, especially among endurance athletes (EA). Unfavorable changes in physical activity and nutrition may affect later sports and competition performance. The aims of this study were: (1) to assess the impact of COVID-19 infection and pandemic restrictions on the nutrition and physical activity of EAs and (2) to compare them with the results of cardiopulmonary exercise testing (CPET). In total, 49 EAs (nmale = 43, nfemale = 6, mean age = 39.9 ± 7.8 year., height = 178.4 ± 6.8 cm, weight = 76.3 ± 10.4 kg; BMI = 24.0 ± 2.6 kg·m−2) underwent pre- and post-COVID-19 CPET and fulfilled the dietary and physical activity survey. COVID-19 infection significantly deteriorated CPET performance. There was a reduction in oxygen uptake and in heart rate post-COVID-19 (both p < 0.001). Consuming processed meat and replacing meat with plant-based protein affected blood lactate concentration (p = 0.035). Fat-free mass was linked with consuming unsaturated fatty acids (p = 0.031). Adding salt to meals influenced maximal speed/power (p = 0.024) and breathing frequency (p = 0.033). Dietary and Fitness Practitioners and Medical Professionals should be aware of possible COVID-19 infection and pandemic consequences among EA. The results of this study are a helpful guideline to properly adjust the treatment, nutrition, and training of EA.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

After SARS-CoV-2 infection, strict recommendations for return-to-sport were published. However, data are insufficient about the long-term effects on athletic performance. After suffering SARS-CoV-2 infection, and returning to maximal-intensity trainings, control examinations were performed with vita-maxima cardiopulmonary exercise testing (CPET). From various sports, 165 asymptomatic elite athletes (male: 122, age: 20y (IQR: 17-24y), training:16 h/w (IQR: 12-20 h/w), follow-up:93.5 days (IQR: 66.8-130.0 days) were examined. During CPET examinations, athletes achieved 94.7 ± 4.3% of maximal heart rate, 50.9 ± 6.0 mL/kg/min maximal oxygen uptake (V̇O2max), and 143.7 ± 30.4L/min maximal ventilation. Exercise induced arrhythmias (n = 7), significant horizontal/descending ST-depression (n = 3), ischemic heart disease (n = 1), hypertension (n = 7), slightly elevated pulmonary pressure (n = 2), and training-related hs-Troponin-T increase (n = 1) were revealed. Self-controlled CPET comparisons were performed in 62 athletes: due to intensive re-building training, exercise time, V̇O2max and ventilation increased compared to pre-COVID-19 results. However, exercise capacity decreased in 6 athletes. Further 18 athletes with ongoing minor long post-COVID symptoms, pathological ECG (ischemic ST-T changes, and arrhythmias) or laboratory findings (hsTroponin-T elevation) were controlled. Previous SARS-CoV-2-related myocarditis (n = 1), ischaemic heart disease (n = 1), anomalous coronary artery origin (n = 1), significant ventricular (n = 2) or atrial (n = 1) arrhythmias were diagnosed. Three months after SARS-CoV-2 infection, most of the athletes had satisfactory fitness levels. Some cases with SARS-CoV-2 related or not related pathologies requiring further examinations, treatment, or follow-up were revealed.

Cardiovascular Concerns from COVID-19 in Pilots

BACKGROUND: Cardiovascular disease, now complicated by the COVID-19 pandemic, remains a leading cause of death and risk for sudden incapacitation for pilots during flight. The capacity for aeromedically significant cardiovascular sequelae with potentially imperceptible clinical symptoms elicits concern both during and following resolution of acute COVID-19 in pilots.OBJECTIVE: We summarize the current state of knowledge regarding COVID-19 cardiovascular implications as applied to the aviation environment to better understand their significance toward flight safety and application toward a focused cardiovascular screening protocol following recovery from infection.METHODS: A narrative review of the cardiovascular implications of COVID-19 infection was performed using the PubMed literature search engine and existing organizational guidelines. In addition, to established medical aviation benchmarks, surrogate populations examined included high performance athletes (as a correlate for high G-forces), and scuba divers (as an environmental work analog). Conditions of primary concern included myocardial injury, proarrhythmic substrates, risk of sudden death, myopericarditis, pulse orthostatic lability in response to vigorous activity, cardiovagal dysfunction, and thromboembolic disease.LITERATURE REVIEW: Cardiovascular screening guideline recommendations post-infection recovery are suggested based on profile stratification: airperson flight class, tactical military, and aerobatic pilots. This provides an approach to inform aeromedical decision making.CONCLUSION: Aviation medical examiners should remain cognizant of the clinically apparent and occult manifestations of cardiovascular dysfunction associated with COVID-19 infection when applying return-to-work screening guidelines. This will ensure high flight safety standards are maintained and sudden incapacitation risk mitigated during and following the ongoing pandemic.Elkhatib W, Herrigel D, Harrison M, Flipse T, Speicher L. Cardiovascular concerns from COVID-19 in pilots. Aerosp Med Hum Perform. 2022; 93(12):855-865.

Cardiac Changes Related to COVID-19 in Athletes: A Brief Review

Purpose of Review

To describe the cardiac changes related to COVID-19 in athletes, in addition to presenting the current recommendations for cardiac assessment and return to sport after COVID-19 infection.

Recent Findings

The current state of the art suggests that myocarditis and pericarditis are the main cardiac pathologies related to the COVID-19 infection in athletes even after recovery. The criteria for determining and evaluating cardiac conditions are still discussed, as well as what stage of infection do cardiomyopathies occur. Return to sport should be aligned with cardiovascular risk stratification.

Summary

Cardiac changes related to COVID-19 infection have drawn the attention in the sports medicine field, while some questions about the course of the disease and its relationship with physical performance in athletes are still under investigation. In addition, feasible assessment techniques for cardiac assessments should be explored in the future.

COVID-19 in European Soccer: A Public 2-Year Comparison of COVID-19 Case Management and Case Characteristics between the 1st Bundesliga, La Liga, Serie A and the Premier League

To evaluate the extent and characteristics of COVID-19 cases in relation to environmental COVID-19 incidences in the four best European soccer leagues (Bundesliga, Premier League, Serie A and La Liga) from the first of January 2020 until the end of January 2022. Methods: A retrospective evaluation of all publicly available COVID-19 cases in the studied cohorts was performed. The 14-day case incidences from epidemiological national data were used as reference values. The leagues studied are the Bundesliga (Germany), Premier League (Great Britain), Serie A (Italy) and La Liga (Spain). For all cases, the duration of time loss and date of case notification were recorded. Results: League-specific mean time loss due to disease or quarantine per COVID-19 case differs significantly between La Liga (11.45; ±5.21 days) and the other leagues studied (Bundesliga 20.41; ±33.87; p 0.0242; Premier League 17.12; ±10.39; p 0.0001; Serie A 17.61; ±12.71; p < 0.0001). A positive correlation between 14-day national incidence with COVID-19 disease occurrence in soccer leagues was found for all leagues studied. The correlations were strong in the Bundesliga (r 0.5911; CI 0.4249−0.7187; p < 0.0001), Serie A (r 0.5979; CI 0.4336−0.7238; p < 0.0001) and La Liga (r 0.5251; CI 0.3432−0.6690; p < 0.0001). A moderate correlation was found for the Premier League (r 0.3308; CI 0.1147−0.5169; p 0.0026). Odds ratios for altered environmental case risk in the cohorts studied could be calculated for four different national COVID-19 incidence levels (<50/100.000 to >500/100.000). A trend towards shorter COVID-19 case duration in the second half of 2021 was shown for all leagues studied. Conclusions: There was a significantly lower mean time-loss caused by a COVID-19 infection for cases occurred in La Liga compared with the other three leagues studied. For all four leagues studied, a positive, significant correlation of national environmental COVID-19 incidence level and the incidence of COVID-19 cases in the cohort of a football league was found.