Large Registry Reassures on COVID-19’s CV Impact

US registry data show collegiate athletes who contract COVID-19 rarely have cardiac involvement and are extremely unlikely to experience adverse cardiac events in the short term. The findings should reassure athletes, coaches, and parents, as well as the medical community more widely, that the viral infection does not cause insidious damage.

Researchers say their findings, from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA), “suggest that asymptomatic or mildly symptomatic athletes that have fully recovered from SARS-CoV-2 infection may return to sport without cardiac testing.”

An early study using cardiac magnetic resonance (CMR) in mostly younger, nonhospitalized patients, garnered global medical attention after raising concerns about silent heart damage following COVID-19. Subsequent studies in college athletes recovering from COVID-19 indicated that some might be suffering from subclinical myocarditis and damage or other forms of myocardial and pericardial injury, although a larger analysis in professional athletes was more sanguine. In all of the CMR studies published to date, the clinical significance of the imaging findings has remained unclear.

To guide clinicians, the American College of Cardiology (ACC)’s Sports and Exercise Cardiology Council issued a framework for return to play in May 2020 and then updated their advice for adults to include pediatric patients 6 months later. The ACC also teamed up with the American Medical Society for Sports Medicine. As noted by a perspective published midsummer in Circulation, there’s no “one-size-fits-all” answer.

The question now is how the various algorithms apply as knowledge grows about COVID-19’s cardiac implications—in the case of the current registry, specific to collegiate athletes.

Sean M. Lang, MD (Cincinnati Children’s Hospital Medical Center, OH), commenting on the results, said that the study confirms what cardiologists in the community have been seeing: that COVID-19’s risk for young people’s hearts isn’t as drastic as once feared.

“Just to see this over a broad, large population data set is really reassuring,” he told TCTMD, noting that the “information trickles down,” such that clinicians like himself who see pediatric patients can feel better about children going back to participating in activities after having asymptomatic or mildly symptomatic COVID-19.

When new diseases emerge, “we’re always extremely cautious, very worried, unclear of the future, and what happens is we do small studies out of necessity because we have small numbers . . . in our own groups,” Lang explained. This can artificially magnify a handful of abnormalities that are less common on a larger scale, he added.

ORCCA Registry

For the study, published online recently in Circulation, researchers led by Nathaniel Moulson, MD, and Bradley J. Petek, MD (Massachusetts General Hospital, Boston, MA), analyzed prospective data on 19,378 athletes from 42 colleges and universities who were tested for SARS-CoV-2 infection from September through December 2020.

In all, 3,018 (mean age 20 years; 32% women) tested positive and underwent cardiac evaluation. Most of them (n = 2,820) had at least one element of cardiac “triad” testing, whether that be 12-lead ECG, troponin assay, and/or transthoracic echocardiography (TTE); this was followed by CMR only if clinically indicated. Just 198 athletes received primary screening using CMR.

Signs of COVID-19-related cardiac involvement were detected in 0.7% by ECG, 0.9% by cardiac troponin, and 0.9% by TTE. Some form of cardiac involvement—classified as definite, probable, or possible based on T1, T2, and late gadolinium enhancement (LGE) findings on CMR—was seen in 0.7% of the entire cohort of athletes, in 0.5% of those who had triad testing, and in 3.0% of those who had primary screening CMR. When CMR was clinically indicated in the triad-testing group, either because of symptoms or due to abnormal ECG/troponin/TTE results, its diagnostic yield reached 12.6%.

Adjusted for race and sex, cardiopulmonary symptoms independently predicted cardiac involvement (OR 3.1; 95% CI 1.2-7.7), as did having at least one abnormal triad test (OR 37.4; 95% CI 13.3-105.3).

Just five athletes were hospitalized for COVID-19 complications, none cardiac. Over a median follow-up of 113 days, one adverse cardiac event occurred (successfully resuscitated sudden cardiac arrest), which the researchers say was likely unrelated to SARS-CoV-2 infection.

Based on their findings, they advise that the full triad of cardiac tests “should be considered in athletes with moderate and/or cardiopulmonary symptoms during initial illness or upon return to exercise.”

CMR, they specify, “is most useful in athletes with high pretest probability for SARS-CoV-2 cardiac involvement as defined by the presence of cardiopulmonary symptoms and/or abnormalities on cardiac testing (ECG, troponin, TTE); however, the significance of CMR findings in the absence of symptoms remains unknown.”

Moulson, Petek, and colleagues call for further studies that involve extended follow-up and control populations without SARS-CoV-2, saying these can inform risk stratification and refine screening strategies.

CMR in COVID-19

One difficulty with CMR is that the process of detecting LGE or scar can be “a little bit subjective,” Lang pointed out, adding, “A lot of it has to do with patients’ pretest probability, their clinical symptoms that make you wonder whether they do or do not have any issues.”

Prior to the pandemic, CMR would most often be done when there was already suspicion of myocarditis, he said. Concerns about potential overuse of CMR inspired an international group of physicians to send an “open letter” to US and European cardiovascular societies in September calling for “clear guidance discouraging CMR screening for COVID-19-related heart abnormalities in asymptomatic members of the general public.”

This paper, said Lang, highlights on a large scale that CMR is best applied only when clinically indicated.

As to what should come next, he said much needs to be learned about long COVID. “We’ve certainly struggled with that with some of our high school-level athletes,” Lang noted. “We’ve been recommending slow resumption of normal activities, if anything just as a way of getting back to some semblance of normal. . . . There’s definitely a stress level to this with previously healthy people who continually have symptoms.”

The COVID-19 pandemic also reinforces the idea that people need to be trained in CPR and that automated external defibrillators should be readily available in case someone has cardiac arrest during physical activity. “That’s far and away going to be the most lifesaving intervention that we can do, [which is to] be prepared for these extremely rare risks rather than screening populations trying to find those who are at risk,” Lang stressed.