Cardiovascular Evaluation After COVID-19 in 137 Collegiate Athletes: Results of an Algorithm-Guided Screening
Authors: Benjamin S. Hendrickson, Ryan E. Stephens, James V. Chang, Jacob M. Amburn, Lindsey L. Pierotti, Jessica L. Johnson, John C. Hyden, Jason N. Johnson, Ranjit R. Philip
Journal: Circulation (2021)

Concerns for cardiovascular sequelae of coronavirus disease 2019 (COVID-19), including myocardial injury or myocarditis, brought about recommendations for evaluating athletes after infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1Assessments that were based on symptoms, disease severity, and cardiovascular testing were refined to guide decision making and safe return to play in various groups. 2However, cardiac magnetic resonance (CMR) findings of myocarditis in athletes have ranged from as high as 15% (4 out of 26 athletes in one study) to as low as 1.4% (2 out of 145 athletes in another study), many of whom had no or only mild symptoms, have raised concerns around testing in this population. 3,4 CMR is a recognized tool for diagnosing myocarditis yet is not generally recommended for athletes after COVID-19 without an elevated index of suspicion. 2,5 Given limited data in competitive athletes after infection with SARS-CoV-2, we report our initial experience with an algorithmguided screening of collegiate athletes and intermediate-term follow-up.Collegiate athletes were evaluated in sports cardiology clinic no sooner than 10 days after testing positive for SARS-CoV-2 by reverse transcriptase polymerase chain reaction.A 12-lead ECG, transthoracic echocardiogram, and conventional cardiac troponin I (cTn) level were obtained from all athletes regardless of symptom history or illness severity.Anyone with an abnormal test result or clinical evaluation of concern was referred for CMR.Those with normal evaluations and negative testing results or negative CMR were returned to full participation after a graduated reintroduction of exercise.Clinical follow-up occurred through communication with university athletic staff.The study was approved by the University of Tennessee Institutional Review Board.The data will be made available on reasonable request.We evaluated 137 athletes from July 9, 2020, to October 21, 2020.Athletes were young adults (median, 20 years; range, 18-27 years), majority male (n=93, 68%), and of various racial/ethnic backgrounds (Black, n=66, 48%; White, n=65, 47%; Hispanic, n=10, 7%).Median time to evaluation was 16 days (interquartile range, 12-34).A broad range of athletics was represented: football (n=51, 37%), dance (n=18, 13%), basketball (n=16, 12%), baseball (n=13, 10%), tennis (n=8, 6%), softball (n=7, 5%), soccer (n=7, 5%), cheer (n=6, 4%), track (n=5, 4%), volleyball (n=4, 3%), and golf (n=2, 1%).Students represented 3 universities and competed across National Collegiate Athletic Association Divisions 1 (majority), 2, and 3.Most athletes were symptomatic (n=112, 82%) and experienced only mild (n=75, 67%) or moderate (n=37, 33%) symptoms.The most frequent symptoms were loss of smell/taste (n=65, 58%), fever (<2 days, n=47, 42%), headache (n=46, 41%), and fatigue (n=45, 40%).Less frequently, shortness of breath (n=14, 12%) and chest pain/tightness (n=13, 11%) were reported.Black and