For sports fans across the country, the resumption of the regular sports schedule was another step towards normalcy after the pandemic. But for athletes in professional, college, high school and even recreational sports, there are important unanswered questions about the effects of COVID-19 infection.
The main question is whether the coronavirus can damage his heart, putting him at risk of lifelong complications and death. Preliminary data from the first days of the pandemic suggest that one in five people taking COVID-19 may develop a heart infection, known as myocarditis, which has been linked to abnormal heart rhythms and sudden cardiac death.
Screening studies conducted by university athletics programs in the past year have generally found lower rates. But these studies were too small to provide an accurate assessment of the likelihood of athletes developing heart problems after taking COVID-19 and the severity of those heart problems.
In the absence of definitive data, there was concern that premature game resumption would expose thousands of athletes to serious cardiac complications. On the other hand, if fears are exaggerated, testing protocols can unfairly disqualify athletes and subject them to unnecessary testing and treatment.
The last thing we want is to overlook people we could potentially recognize, which would lead to poor outcomes – especially the sudden death of a young athlete, said Dr. Matthew Martinez, director of sports cardiology at Atlantic Health’s Morristown Medical Center in New Jersey and a consultant to several professional sports leagues. But we also need to look at the downside and the potential negative consequences of a new test.
With millions of Americans playing sports in high school, college, pro or championships, even a low complication rate can lead to a significant number of injuries in athletes. And that could lead to a lively debate on how to balance the risk of the small percentage of players who may be at risk with the continuation of competitive sport as we know it.
Limited impact on professional sport
The data released by professional sports federations in early March reassured us, at least to some extent, that the problem may not be as big as first feared. Professional athletes playing football, men’s and women’s basketball, baseball, soccer and hockey were tested for heart problems before returning from infection with COVID-19. The players underwent an electrical heart rate test, a blood test checking for heart damage and a heart ultrasound. Of the 789 athletes tested, 30 showed heart abnormalities in these initial tests and were referred for MRI to get a better picture of their hearts. Five athletes, or less than 1% of the athletes surveyed, were diagnosed with heart inflammation, preventing them from competing for the remainder of the season.
Boston Red Sox pitcher Eduardo Rodriguez returned to spring training in 2021 after he was diagnosed with myocarditis and missed the entire 2020 season. Billy Weiss/Getty Images
The researchers who compiled the data did not name the players, although some disclosed their diagnosis. Boston Red Sox pitcher Eduardo Rodriguez returned to the mound this spring after missing the 2020 season following a diagnosis of COPID-19 and myocarditis. Similarly, Tommy Sweeney was on his way back from a leg injury when he was diagnosed with myocarditis in November.
In college, many have speculated that Keyontae Johnson, a 21-year-old offensive player on the University of Florida basketball team who fell on the court in December, months after he signed with COVID-19, may have developed myocarditis. That same month, the Gainesville Sun reported that he had been diagnosed with inflammation of the heart muscle, but his family issued a statement in February saying the incident had nothing to do with COVID and declined to provide further details.
Effect not yet clear
Doctors still do not know how important the results of MRI of myocarditis are for athletes. Tests that look for rare medical events often produce more false positives than true positives. And without comparing the results to those of athletes who did not have COVID-19, it is difficult to determine which changes are due to the virus and which may simply be the result of athletic training or other causes.
Training profoundly alters the heart of athletes, and what may seem interesting to another patient may be quite normal for an elite athlete. Many endurance athletes have Z’s. B. have a larger than average left ventricle and pump a smaller proportion of blood with each contraction. This would be a cautionary tale for patients who are not elite athletes.
There may certainly be a gray area where extreme forms of athletic cardiac remodeling may actually resemble pathology, said Dr. Jonathan Kim, a sports cardiologist at Emory University in Atlanta. COWID has introduced a new challenge. Is it because they are crossing over or because they just had a COVID?
In addition, myocarditis is usually diagnosed by symptoms – chest pain, shortness of breath, weakness of the heart muscle or electrical disturbances – and then confirmed by an MRI. It is unclear whether MRI findings resembling myocarditis in the absence of these symptoms are of equal concern.
You have routine medical examinations. His cardiograms are normal. Nothing else happens, says Dr. Robert Bonow, a cardiologist at Northwestern University and editor of JAMA Cardiology. But if you ask for an MRI as part of the examination, you start to see very subtle changes because MRI is very sensitive.
Were the anomalies only discovered because they were searching? Even patients who die from COVID-19 have a very low rate of myocarditis, Bonow said.
So what’s going on with the athletes? Is it related to the fact that they had an infection, or is it something very aspecific that is related to the COVID but not the heart damage? he said. There is still a lot of uncertainty.
Sports cardiologists involved in collecting sports data and developing screening guidelines for athletes said the fact that players were able to continue their season without serious heart complications suggests that initial concerns were exaggerated. Of the players who presented with mild or asymptomatic cases of COVID-19, none were ultimately diagnosed with myocarditis and none developed persistent cardiac complications in 2020. Many have finished their 2020 season and have already started the next.
We overreacted, Martinez said. This shows what our policy reflects: The prevalence of heart disease in this condition is unusual in a population of athletes.
Falling through the net
These screening guidelines, released in October by a group of leading sports cardiologists, call for cardiac testing only for athletes with moderate to severe symptoms of COPID-19. Athletes with asymptomatic cases or mild symptoms that have resolved may return to play without further testing. The National Federation of State High School Associations and the American Medical Society for Sports Medicine have published similar guidelines for high school athletes.
But with this approach, there would be no figureheads like Demi Washington.
Washington, a 19-year-old sophomore on the Vanderbilt women’s basketball team, had a fairly mild case of COVID-19. She shared the meal with two teammates, one of whom was later found to be infected. After seven days of a two-week quarantine in an off-campus hotel, Washington was also found to be positive and had to remain isolated for another 10 days due to a stuffy nose. She waited for her symptoms to get worse, but they didn’t.
She said it was like an allergy.
But when her symptoms disappeared and she resumed her education, the university required her to undergo several tests to make sure the virus had not affected her heart. The first tests showed that there were no problems. MRI showed acute myocarditis.
The season is over, but more importantly, Washington, an athlete with high fitness, was faced with the possibility of losing her life. She learned the story of Hank Gathers, the 23-year-old basketball star from Loyola Marymount who fell during a game in 1990 and died hours later. His autopsy confirmed an enlarged heart and myocarditis.
It really kept me on my toes, Washington said. I am: Okay, I have to take this seriously because I don’t want to end up like this.
Demi Washington Vanderbilt (left), who averaged 3.8 points per game as a freshman, did not participate in the 2020-21 season after an MRI revealed acute myocarditis. Mark Humphrey/AP Photo
For months she had to keep her heart rate below 110 beats per minute. She walked 5 miles every day. Having been diagnosed with myocarditis, she had to wear a heart monitor, and even a brisk walk can get her over that threshold.
One day I was on my way to the gym and I was walking maybe a little too fast, Washington recalls. My breasts were getting very, very tight.
In mid-January, however, a new MRI showed that the inflammation had subsided, and she has been training again since.
I’m so grateful that Vanderbilt is getting an MRI, because without it, there’s no telling what would have happened, she said.
She wondered how many other athletes were playing with myocarditis without knowing it.
Cases like Washington raise questions about how to aggressively protect. His condition was only discovered because Vanderbilt took a much more conservative approach than current guidelines recommend: He examined all athletes who underwent cardiac MRI after taking COVID-19, regardless of the severity of their initial cardiac symptoms or tests.
Of the 59 athletes screened for COVID, the university found two with signs of myocarditis. That’s just over 3%.
Is the current level of myocarditis we see high enough to continue cardiovascular screening? asked Dr. Daniel Clark, a sports cardiologist at Vanderbilt and lead author of the school’s screening analysis. Five percent is too much to ignore in my opinion, but what is our societal threshold for not screening competitive athletes for myocarditis?
Although myocarditis is rare, studies have shown that non-COVID myocarditis causes up to 9 percent of sudden cardiac deaths in athletes, said Dr. Jonathan Drezner, director of the University of Washington’s Sports Cardiology Medical Center, which advises the NCAA on cardiology issues. COVID-19 therefore represents a new risk. The NCAA alone has over 480,000 athletes. To give an impression of scale: If all of these athletes were administered COVID-19 and even just 1% of them were at risk of heart problems, that would be 4,800 athletes.
Awaiting additional information
Doctors are now waiting for the release of data from thousands of athletes who were examined after contracting COVID-19 last year. The American Heart Association and the American Medical Society for Sports Medicine have established a national registry to track cases of OHVID-19 and heart disease in NCAA athletes, with more than 3,000 athletes in the registry, while the Big Ten Conference maintains its own registry.
The data from this registry can ultimately be used to analyze who is at greatest risk for heart complications, determine who should be screened, and improve the reliability of testing. Doctors may find that some symptoms are better risk indicators than others. Then genetic or other tests can be used to determine who is most at risk.
But will small schools have the resources and expertise to monitor all their athletes?
What about all colleges, all Division III, Division II programs? Martinez said. Many of them say: Look, forget it. If we do all those extra tests, we can’t do it.
The new data from professional sports should reassure these colleges and even high schools, he said, because the vast majority of healthy young athletes who use COVID-19 usually have mild or asymptomatic infections and don’t need additional testing.
The same recommendations apply to amateur athletes. People with mild or asymptomatic VID-19 can return to exercise slowly without much concern after symptoms disappear. People with moderate to severe cases should consult with their doctor before returning to exercise.
Slight academic problems
Large, affluent universities like Vanderbilt have state-of-the-art medical facilities with the resources and expertise to properly interpret cardiac magnetic resonance imaging. Small schools can have a difficult time selecting their athletes.
According to Dr. Dermot Phelan, a sports cardiologist at Atrium Health in Charlotte, N.C., there are only a handful of centers in the country that have the real expertise to effectively perform cardiac MRIs in athletes. And the reality is that these systems are already overloaded when processing normal clinical data. Adding a large number of athletes to that would put pressure on the medical system, I think.
Some schools with limited testing resources may decide that athletes recovering from moderate to severe VaDOC-19 should sit on the bench rather than risk a devastating event. Others may allow athletes to return to play after their recovery and monitor them for signs of heart complications. Many NCAA schools have installed automatic external defibrillators if an athlete falls during a game or practice.
They are thinking of the 100,000 high school students whose parents have been affected: Do they have access to anyone who knows anything about it? On the other hand, these are young people who don’t actually have COVID, said Dr. James Udelson, a cardiologist at Tufts Medical Center in Boston. Our concern is that we don’t know much.
Some schools are also concerned about their liability if they allow players to return after being infected with COVID-19 without being able to get a proper cardiac evaluation.
Whatever precautions a college or university takes in this regard, they can still be sued, said Richard Giller, an attorney with Pillsbury Winthrop Shaw Pittman in Los Angeles. The question is whether they have a responsibility. I think it will depend on a number of factors, not the least of which is who recommended the student-athletes who have contracts with COVID-19 to return.
He advises universities not to rely solely on university doctors, but to require students to consult their own doctors when making the decision to play again. Teams can also have players sign a waiver so they understand that cardiac complications can occur when they return to play after a COVID-19 infection.
Some colleges have asked students to sign a waiver absolving the school if a player signs a contract with COVID-19. But the NCAA has ruled that schools cannot make these exceptions a game condition.
Doctors don’t know what might happen in the long run. After only one year of experience with COVID-19, it is not known whether the myocarditis visible on MRI will disappear quickly or whether late effects may lead to complications years later.
Many people are concerned about what we don’t yet know about COVID-19 and the athlete’s heart, and about the handful of cases that may escape discovery.
You can put a group of athletes through all the heart tests and have them come out the other side, but one of them will eventually die, Phelan said. The reality is that there is nothing you can do to be 100% sure.
Markian Khavriluk is a reporter for KHN. ESPN’s Paula Lavigne and Mark Schlabach contributed to this report.
KHN (Kaiser Health News) is a national news outlet that produces in-depth journalism on health issues. Along with policy analysis and surveys, KHN is one of the Kaiser Family Foundation’s (KFF) three main operating programs. The KFF is a recognized nonprofit organization that provides health information to the nation.
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