Post-COVID-19 peri- and myocardial manifestations are less common in athletes than in healthy non-athletes: findings from a systematic review

Abstract

Background/Introduction: The prognosis of peri-and myocarditis can be negatively influenced by intensive exercise and sports. Therefore sustained cardiac involvement after recovery from COVID-19 in athletes is of particular relevance for the prevention of sudden cardiac arrest/sudden cardiac death (SCA/SCD). To date, only small sample-size studies are available, or studies predominantly focusing on hospitalized and severely ill patients. We aimed to address this knowledge gap in a comprehensive, systematic review of peri-/myocardial involvement after SARS-CoV-2 infection in athletes versus healthy non-athletes. Purpose: Quantification of peri-/myocardial involvement and risks of SCA/SCD after SARS-CoV-2 infection in athletes as compared with healthy non-athletes. Methods: We performed a systematic search with a combination of key terms in Medline (Ovid), Embase (Ovid) and Scopus (through March 8th 2021). To capture potential non-peer-reviewed COVID-19 SCA/SCD reports we performed monthly scoping internet searches. Inclusion criteria: athletes/non-athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion criteria: study population ≥1 individual comorbidity and mean age <18/>64 years. Results: We included 16 manuscripts (933 papers reviewed) comprising 1129 athletes (284 college/student-, 807 professional-and 38 elite athletes) and 382 healthy non-athletes. Athletes vs non-athletes reported myocarditis on echocardiography and/or CMR in 0-15% vs 45-60%, LGE in 0-46% vs 0-74% (Figure 1), and pericardial effusion in 8-58% vs 0-47% (Figure 2). Weighted means of diagnosed myocarditis were 3% in athletes (3.5% college/student-, and 0% elite athletes) and 56.6% in non-athletes. No important arrhythmias were reported. Systematic internet query identified 2 collapsed post-COVID-19 athletes during exercise, 1 lethal. Ten studies (n=1301) reporting post-recovery troponin T/I found no clear relationship with cardiac abnormalities. Summary/Conclusions: Rates of peri-/myocardial abnormalities in athletes/ healthy non-athletes after SARS-CoV-2 infection are variable, ranging from 0-74%, and predominantly seen on CMR. Athletes have a lower risk of peri-/myocardial involvement, and myocarditis (0-3.5% vs 56.5%) than non-athletes after SARS-CoV-2 infection. Risks of SCA/SCD appear low, but data are lacking. Troponin screenings seems unreliable to identify athletes at risk for myocardial involvement. Prospective studies, with pre-COVID-19 imaging (CMR), in athletes, including follow-up and arrhythmia monitoring, are urgently needed.