Elite Athletes Recover Strong: No Long-Term Cardiac Risks After COVID-19 Recovery

In a recent article published in the magazine HeartResearchers evaluated the long-term effects of resuming elite sports on heart 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-level performance.

Study: Long-term cardiac monitoring of athletes infected with SARS-CoV-2 after resumption of elite sports. Image Credit: Jacob Lund/Shutterstock

Background

Human studies during active myocarditis are lacking for ethical reasons. However, studies in mice have shown that strenuous physical activity, for example elite sports, could lead to serious cardiac effects, including ventricular tachyarrhythmias and mortality.

Consequently, doctors prevent athletes diagnosed with active myocarditis from playing sports, which could negatively affect their professional careers. In fact, active myocarditis is considered an absolute contraindication to playing 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 of great clinical relevance.

However, cross-sectional studies focusing primarily on the prevalence of cardiac aberrations and return to sports (RTS) screening protocols are lacking, and prospective studies investigating the long-term outcomes of sports participation on cardiac health after COVID-19 are lacking. 19.

About the study

In the present prospective controlled study, investigators recruited Olympic, Paralympic, and other professional athletes from the Evaluation of Lifetime Participation in High-Level Intensive Sports and Exercise (ELITE) longitudinal cohort who were ≥16 years of age, with an exercise routine of ≥10 h/week to compete in high-level sports.

They then subjected athletes with confirmed COVID-19 from the ELITE cohort to structured cardiovascular examinations, including electrocardiography (ECG), laboratory evaluations, and cardiovascular magnetic resonance (CMR). These athletes constituted the ‘Myocardial Manifestations of COVID-19 in High-Level Intensive 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 ELITE athletes infected and uninfected with SARS-CoV-2. Additionally, they examined long-term detrimental cardiac effects, including adverse cardiac events and ventricular arrhythmia burden, to determine whether SARS-CoV-2 infection led to cessation of their athletic careers.

Additionally, when CMR of an athlete infected with SARS-CoV-2 demonstrated cardiac abnormalities, the team repeated CMR evaluations three, six, and nine months after infection. The researchers also collected each participant’s age, gender, ethnicity (sociodemographic data), athletic discipline, and time spent playing professional-level sports.

Results

Of 259 athletes recruited to COMMIT, 123 recovered from a SARS-CoV-2 infection and 136 formed the uninfected control group. Athletes infected with SARS-CoV-2 were younger and less likely to be of Caucasian ethnicity; Additionally, 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 those of controls.

Based on CMR results before and after infection, SARS-CoV-2 infection showed no detrimental effects on CMR volumetric and functional parameters of all athletes who resumed elite sports. The prevalence of perimyocardial involvement (cardiac sequelae of SARS-CoV-2) was extremely low (3%), with a temporally variable clinical presentation and course.

Only four SARS-CoV-2-infected athletes demonstrated non-ischemic pathological patterns of myocardial LTR, with some athletes showing complete resolution of LTR, while others had persistent LTR but without signs of inflammation.

Even in ELITE athletes with cardiac sequelae who resumed competitive sports, no harmful morphological alterations or ventricular arrhythmias were observed. Furthermore, the authors did not observe any new again or adverse cardiac events in athletes during two years of follow-up, regardless of cardiac problems triggered by SARS-CoV-2 at the initial post-infection evaluation.

Conclusions

Athletes participating in elite sports constitute a distinctive phenotype to investigate the role of physical activity as a trigger of post-COVID-19 adverse cardiac remodeling.

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 cessation of a professional athletic career, regardless of the presence or absence of cardiac sequelae.

A reduction in left ventricular remodeling index in individuals with CMR measurements before and after COVID-19 showed the effect of detraining during the COVID-19 pandemic; however, COVID-19 did not cause detrimental ventricular volumetric and functional changes.

In general, successful RTS can be achieved, even for athletes with myocardial abnormalities, albeit with appropriate counseling during return-to-sports trajectories. Data from the study could also help design evidence-based protocols for safe RTS after SARS-CoV-2 infection for all athletes.