Had COVID-19? ‘Hidden’ CV Damage Warrants Cautious Return to Physical Activity

For some, the start of summer sees running shoes, bicycles, and rollerblades back in heavy rotation. But for people who’ve recovered after contracting COVID-19, even a mild course, experts are urging caution as they return to routine physical activity and sports.

In a new perspective published online June 9, 2020, in Circulation, Aaron Baggish, MD (Brigham and Women’s Hospital, Boston, MA), and Benjamin Levine, MD (UT Southwestern Medical Center, Dallas, TX), ask physicians and patients to be aware of potentially unrecognized cardiac complications of COVID-19 that could be dangerous when high-intensity or high-volume exercise is added to the mix.

“We really wanted to make the point that there’s not going to be a ‘one size fits all,’” Baggish told TCTMD. “What you do, and the rapidity in which you return [to exercise and sports], is going to be dependent on the resources you have available. Getting the Boston Bruins or Toronto Maple Leafs back on the ice is a different thing than opening up the rink to other teams or bringing marathon runners back to your city. It’s not going to be about turning on the light switch and then seeing what happens. There needs to be a staged and thoughtful approach to this whole thing.”

It’s not going to be about turning on the light switch and then seeing what happens. Aaron Baggish

In their paper, Baggish and Levine urge people recovered from the virus to learn from the myth of Icarus who, so ecstatic to have taken flight on wings of feathers and wax, flew too close to the sun. Community athletes and weekend warriors can’t ignore the cardiovascular risks altogether, but they also don’t need to be prohibitively conservative in their return to activity.

“The bookends of the spectrum are probably the easiest to discuss,” said Baggish. “People who were fully asymptomatic, or those in whom there was never any question of having clinically relevant COVID-19, are almost certainly perfectly fine to continue doing their exercise or getting back into whatever sport they want to do. On the other end, you have people who were sick enough to be hospitalized. There, I really think they need to be seen by a doctor, preferably a cardiologist, to have an evaluation. In hospitalized patients, roughly one-third end up with some form of heart muscle damage. We just don’t know what that’s going to mean for getting people back into high-level exercise. They need to be seen and followed carefully.”

Jonathan Kim, MD (Emory School of Medicine, Atlanta, GA), a member of the American College of Cardiology Sport and Exercise Council, said COVID-19 isn’t going anywhere anytime soon so there have been a lot of requests for guidance on how to safely resume sports, physical activity, and exercise after a positive diagnosis. Last month, Kim, along with Dermot Phelan, MD, PhD (Sanger Heart and Vascular Institute, Charlotte, NC), and Eugene Chung, MD (University of Michigan, Ann Arbor), published a similar “game plan” for the resumption of sports and exercise after a course of COVID-19.

“There’s been a lot of attention given to this, and it’s only going to continue to get busier,” said Kim. The current return-to-play recommendations—both from his group and those suggested by Baggish and Levine—are “somewhat conservative,” especially for asymptomatic patients or those with a mild case, but that approach is warranted given how little is known about the cardiac manifestations of COVID-19 in lesser ill patients, he said. “Ultimately, as athletes come back—and they’re coming back, and I don’t think there’s anything wrong with that—we just have to understand that this is new territory.”

Bookends Easiest to Discuss

Although still a novel disease with considerable evidence gaps, experts now know that COVID-19 has important adverse effects on the cardiovascular system, especially in severely ill patients requiring hospitalization. Persistent myocardial edema, fibrosis, and impaired cardiac function have been noted following infection, and COVID-19-related myocarditis has been linked with a higher risk of mortality. Unfortunately, much of the research regarding the cardiovascular implications of COVID-19 is derived from sicker patients, which makes it a challenge to understand the impact in asymptomatic patients or those with mild disease, say experts.

“Cardiac injury occurs in 20% to 30% of hospitalized patients with COVID-19,” said Kim. “If you look at other acute viral infections, it’s around 1%. Again, this is in the sicker patients, but it has triggered alarms for our lesser-ill patients.”

In their return-to-play algorithm for asymptomatic patients with a positive diagnosis, Baggish and Levine recommend rest/no exercise for 2 weeks following the positive test, close monitoring for symptom onset or late deterioration, and a slow resumption of activity after the 14 days. “As long as they have been 2 weeks out from symptoms, they can start getting back into exercise,” said Baggish. “They should ease in slowly and pay attention to how they feel. If there are warning signs that things aren’t normal—if they’re feeling palpitations, chest pain, or unusually labored breathing for what they’re doing—that should be a signal to stop and get some medical advice sooner rather than later.”

If you have no symptoms or you’re mildly ill, is there a degree of subclinical cardiac injury? Jonathan Kim

For the patient with mild symptoms who wasn’t hospitalized, an evaluation that includes cardiac troponin testing, 12-lead electrocardiogram, echocardiography, or other tests might be prudent depending on the clinical situation. For those with an abnormal troponin test and/or cardiac study, it is recommended these patients follow the American College of Cardiology/American Heart Association’s myocarditis “return-to-play” guidelines.

Baggish acknowledged that cost and access to downstream cardiac screening is an important variable. For that reason, they don’t advocate widespread cardiac screening in all COVID-19 patients, but do recommend that people try to return to normal exercise routines and seek out a medical assessment if things don’t feel right. “We don’t want to overwhelm the system,” he said. “We don’t want doctors testing people that don’t need it. But I think if you’ve had COVID-19, and you’re exercising and feeling unwell, it’s enough of a concern that it’s a reasonable ask of the healthcare system.”

To TCTMD, Kim said one major concern with COVID-19 is the subsequent development of myocarditis. Engaging in intense physical exercise with active myocarditis can worsen the condition and lead to life-threatening arrhythmias. “And we know that myocarditis is a cause of sudden cardiac death in athletes,” said Kim. “Thinking about it logically, we’re seeing the injury in sicker patients, and we’re not entirely sure what’s causing that injury, but myocarditis is certainly one of those causes, and that leads to many questions. If you have no symptoms or you’re mildly ill, is there a degree of subclinical cardiac injury? We don’t have the answers to that right now.”

The return-to-play algorithm proposed by Kim, Phelan, and Chung is similar to the one proposed by Baggish and Levine. Overall, Kim said sports cardiologists are adopting a careful approach, even in those who are feeling well. “Until we have data to know what is really going on, we’re going off what’s known in the sicker COVID-19 folks, knowing what the implications could be and therefore starting off with more of a cautious approach,” he commented.