key: cord-1022323-zgb6xfsy
authors: Oikonomou, Evangelos; Papanikolaou, Angelos; Anastasakis, Aris; Bournousouzis, Elefterios; Georgakopoulos, Christos; Goudevenos, John; Ioakeimidis, Nikolaos; Kanakakis, John; Lazaros, George; Papatheodorou, Stathis; Tsatsopoulou, Adalena; Tsonou, Paraskevi; Vogiatzi, Georgia; Panagiotakopoulos, George; Tousoulis, Dimitris; Vlachopoulos, Charalambos
title: Proposed algorithm for return to sports in competitive athletes who have suffered COVID-19
date: 2020-07-04
journal: Hellenic J Cardiol
DOI: 10.1016/j.hjc.2020.06.012
sha: f16b8e7ae8e902d39b7689512951d4aa7f1cffe3
doc_id: 1022323
cord_uid: zgb6xfsy

nan

Coronavirus disease 2019 (COVID- 19) is an acute respiratory disease of various severity caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) [1, 2] . Cardiovascular system is the second most significant target of COVID-19 [3] and involvement includes acute myocardial injury, myocarditis, arrhythmias and venous thromboembolism. Reports document that in patients with COVID-19 the incidence of myocardial injury is estimated at 28% and is associated with fatal outcome [4] . In the acute phase of myocarditis exercise may exacerbate viral replication, inflammation, myocardial cell death, arrhythmias and may adversely affect the outcome leading to morbid complications.

Taken into consideration the uncertainties regarding prevalence of asymptomatic COVID-19 cases in the community, the incidence of myocardial injury in COVID-19 patients with mild symptoms and the long term outcome of COVID-19, public health policy is required to guide the return-to-sports decision making should be performed during acute illness or at least before resumption of competitive sport activities. High-sensitive troponin tests can be used to diagnose myocardial injury during the acute phase and up to 14 days following recovering from disease.

In case that the initial cardiological evaluation reveals abnormal findings, further evaluation should be applied. In particular, cardiac magnetic resonance imaging (cMRI) may detect myocardial involvement, such as features of acute myocarditis, confirming the diagnosis and adding prognostic information. Ambulatory ECG recordings should be applied to evaluate the arrhythmic burden. If clinical and diagnostic evaluation fulfills the diagnostic criteria of clinically suspected myocarditis, coronary artery disease should be excluded with coronary angiography (computed tomography or conventional) and if so, the athlete should be treated according to myocarditis guidelines [5] . In this case a 6-month period of exercise restriction should be applied along with a recommendation for thorough cardiac reevaluation after this time-period [5, 7, 8] .

If cardiac evaluation reveals abnormal findings but the diagnostic criteria of clinically suspected myocarditis are not fulfilled (i.e. isolated temporary elevation of high sensitive troponin levels above reference limits) then alternatives diagnosis should be considered (namely myocardial injury) and a 3-month period of exercise restriction should this time be recommended with re-evaluation before resumption of athletic activities [6] .

Cardiopulmonary exercise stress test or stress test is recommended before resumption to activities in case of either myocardial injury or clinically suspected acute myocarditis.

In case of deterioration of the clinical status during the acute phase, or detection of persisting cardiac abnormalities after the recommended period of restricted activities further evaluation (e.g. with endomyocardial biopsy, etc.) in specialized units is advised.

Since there are no definite data on the short-and long-term cardiovascular complications by COVID-19 the proposed approach is based on expert opinion and is subject to further refining as knowledge on the course of COVID-19 accumulates. 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic

The Greek study in the effects of colchicine in COvid-19 complications prevention (GRECCO-19 study): Rationale and study design

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease

Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases

Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology

Current perspectives on the diagnosis and management of dilated cardiomyopathy Beyond heart failure: a Cardiomyopathy Clinic Doctor's point of view

Recurrent viral myocarditis: The emerging link toward dilated cardiomyopathy