Importance of Shared Decision Making for Return to Play After COVID-19
Authors: Benjamin H. Hammond, Peter F. Aziz, Dermot Phelan
Journal: Circulation (2021)

HomeCirculationVol. 143, No. 18Importance of Shared Decision Making for Return to Play After COVID-19 Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBImportance of Shared Decision Making for Return to Play After COVID-19 Benjamin H. Hammond, Peter F. Aziz and Dermot Phelan Benjamin H. HammondBenjamin H. Hammond Benjamin H. Hammond, MD, Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9899-145X Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, OH (B.H.H., P.F.A.). , Peter F. AzizPeter F. Aziz Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, OH (B.H.H., P.F.A.). and Dermot PhelanDermot Phelan Sports Cardiology Center, Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC (D.P.). Originally published16 Mar 2021https://doi.org/10.1161/CIRCULATIONAHA.120.052372Circulation. 2021;143:1733–1734Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 16, 2021: Ahead of Print The potential for coronavirus disease 2019 (COVID-19)–related cardiac injury to result in major adverse events, including sudden cardiac death, has become a major source of fear for those who look after athletes. In hospitalized patients, cardiac injury is associated with worse outcomes.1 Although the prevalence of COVID-19–related myocarditis has not been well established in athletes, such concerns have been reflected in proposed return-to-play recommendations that suggest that athletes deemed at risk of cardiac injury on the basis of their symptoms should undergo cardiac screening before returning to play.2Unfortunately, screening is imperfect and can lead to both false-positive and false-negative findings. There are challenges with the interpretation of biomarkers such as cardiac troponin levels, ECGs, and echocardiograms in athletes in whom exercise-induced cardiac remodeling can be misinterpreted as pathology. Small, single-centered studies using cardiac magnetic resonance in both athletes and nonathletes with mild or no symptoms who have recovered from COVID-19 have raised the specter of a high prevalence of subclinical myocarditis.3,4 However, although cardiac magnetic resonance is an excellent tool for diagnosing myocarditis in patients with suspected disease, its use for screening asymptomatic individuals will likely lead to overinterpretation of minor variations of parametric maps and artifact.The primary concern is for myocarditis, a known risk factor for sudden cardiac death in athletes. The current recommendation is that "athletes with probable or definite myocarditis should not participate in competitive sports while active inflammation is present." Athletes with myocarditis are generally restricted from competition for 3 to 6 months and need to undergo rigorous testing before returning to play.With widespread screening of athletes for subclinical myocarditis, cardiologists are likely to encounter patients with ambiguous test results, including mild high-sensitivity troponin elevation, low-normal ventricular function, mild T1 or T2 elevation, or concern for subtle areas of late gadolinium enhancement. The clinical implications of these are particularly uncertain when seen in an asymptomatic individual who had mild symptoms when acutely infected with COVID-19. In addition to ambiguous test results, there is the question of the duration of competitive restriction in those who are considered to have subclinical myocarditis. Last, we have limited understanding of the unique risks related to restarting sports in the context of COVID-19. In the face of uncertain risk, we would advocate for the use of shared decision making (SDM) and safety plans for our athletes returning to play.Recognizing the autonomy of the athlete, SDM is an important framework for counseling patients with uncertain but low risk of adverse events about return to play. The approach involves educating the patient about the potential risks of participation in certain activities, determining the patient's priorities and values, and coming to a joint decision about whether to resume competitive sports. Although sports participation in the past was decided by the physician in a binary fashion, updated guidelines from both the American College of Cardiology and the European Society of Cardiology have shifted emphasis to a more patient-centered model that supports SDM.5 For those with residual uncertain risk, cardiologists can establish safety plans, including refraining from sports participation if symptomatic, strict medication compliance, and mandating the presence of an automated external defibrillator and cardiopulmonary resuscitation–trained bystanders during exercise. Safety plans are particularly relevant in our current situation given the unknown risks our athletes face, even when there is clear evidence of subclinical myocarditis. An environment where athletes are observed with access to automated external defibrillators and trained providers is arguably safer than situations when athletes are training alone.Although SDM is becoming a well-established framework for managing adult athletes with cardiac disease, its application to pediatric populations, who do not have legal autonomy in their own medical decision making, is less well understood. Arguments have been made in the literature to avoid the use of SDM in pediatric athletes, citing their inability to fully comprehend serious risks with feelings of immortality common to youth. Although this may be the case in some young athletes, many young athletes are capable of mature processing sufficient to engage in an SDM process. A consensus understanding of the individual's values, the perceived importance of sporting participation, and the potential risks of restriction or disqualification is further enhanced by the required involvement of an adult parent or legal guardian, with extension then to the adult coaching staff and school administration. We advocate for assessment of each individual's ability to participate with the support and direction of their parents or legal guardians. If the minor is an adolescent with sufficiently mature processing, we would engage in a discussion of risk and safety planning, as we would with an adult athlete. We ensure that the parents or legal guardians recognize their role in owning the athlete's risk as the ultimate decision makers. If the minor is deemed unable to understand all the implications of these decisions, we do not typically engage them in this discussion or offer alternatives to the recommended guidelines. In a similar manner, we do not engage in this process if the parent or legal guardian cannot understand the full implications of decisions for the minor. If the expressed interests of the parent and young athlete do not align, with the parent favoring more or less acceptance of risk than the young athlete, the discussion needs to be suspended until this is resolved between these 2 parties. The financial implications of sports participation should be addressed with emphasis that this not be used as motivation to accept more risk than otherwise might be the case. SDM in minors should be a transparent process with documentation shared with the athlete, parent or guardian, coaching staff, and school leadership as appropriate. In the case of SDM in post–COVID-19 athletes, follow-up after reengagement in sports is essential with suspension of sports eligibility if the athlete develops cardiac symptoms.We propose that cardiologists engage in SDM with their asymptomatic athlete patients with ambiguous test results to allow them the choice to participate in their sport as safely as possible. We advocate for attempting to use SDM in younger athletes with their parents, according to an assessment of mature processing. We acknowledge that this process will differ when considering restriction for a short period of time such as 3 months compared with a lifetime restriction in athletes with certain conditions. We also acknowledge the uncertainty that accompanies such a decision given the lack of clinical evidence and endorse open communication with patients to engage them in this difficult decision.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circBenjamin H. Hammond, MD, Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195. Email hammonb4@ccf.orgReferences1. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China.Intensive Care Med. 2020; 46:846–848. doi: 10.1007/s00134-020-05991-xCrossrefMedlineGoogle Scholar2. Kim JH, Levine BD, Phelan D, Emery MS, Martinez MW, Chung EH, Thompson PD, Baggish AL. Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play.JAMA Cardiol. 2021; 6:219–227. doi: 10.1001/jamacardio.2020.5890CrossrefMedlineGoogle Scholar3. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, Shchendrygina A, Escher F, Vasa-Nicotera M, Zeiher AM, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19).JAMA Cardiol. 2020; 5:1265–1273. doi: 10.1001/jamacardio.2020.3557CrossrefMedlineGoogle Scholar4. Rajpal S, Tong MS, Borchers J, Zareba KM, Obarski TP, Simonetti OP, Daniels CJ. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection.JAMA Cardiol. 2021; 6:116–118. doi: 10.1001/jamacardio.2020.4916CrossrefMedlineGoogle Scholar5. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology.J Am Coll Cardiol. 2015; 66:2343–2349. doi: 10.1016/j.jacc.2015.09.032CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nelis S, Dijkstra H, Damman O, Farooq A and Verhagen E (2024) Shared decision-making with athletes: a survey study of healthcare professionals' perspectives, BMJ Open Sport & Exercise Medicine, 10.1136/bmjsem-2024-001913, 10:2, (e001913), Online publication date: 1-Apr-2024. Akers K (2024) Return-to-Play Post-COVID-19 in 2023: A Pediatric Case Report, Journal of Pediatric Health Care, 10.1016/j.pedhc.2023.11.015, Online publication date: 1-Jan-2024. Corneil H, Liblik K, Varghese S, Masotti B, Moulson N, McKinney J, Allan K, Phelan D, Thakrar A, Johri A and Grubic N (2023) Shared Decision-Making in Athletes Diagnosed With a Cardiovascular Condition: A Scoping Review, Current Problems in Cardiology, 10.1016/j.cpcardiol.2023.101815, 48:10, (101815), Online publication date: 1-Oct-2023. Schmidt T, Bjarnason-Wehrens B, Zacher J, Predel H and Reiss N (2022) Sports, Myocarditis and COVID-19: Diagnostics, Prevention and Return-to-play Strategies, International Journal of Sports Medicine, 10.1055/a-1810-5314, 43:13, (1097-1105), Online publication date: 1-Dec-2022. Temple V COVID-19 Pandemic and Individuals With Intellectual Disability: Special Olympics as an Example of Organizational Responses and Challenges, Adapted Physical Activity Quarterly, 10.1123/apaq.2021-0137, 39:3, (285-302) Qureshi N, Bansal S and Kasapcopur O (2021) Autoimmune Thyroid Disease and Psoriasis Vulgaris after COVID-19 in a Male Teenager, Case Reports in Pediatrics, 10.1155/2021/7584729, 2021, (1-3), Online publication date: 27-Jul-2021. May 4, 2021Vol 143, Issue 18 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.052372PMID: 33724865 Originally publishedMarch 16, 2021 KeywordsCOVID-19exercisePDF download Advertisement SubjectsExercise