Are COVID-19 heart-related issues the reason sports are canceled?

The cardiac effects of COVID-19 have been getting a lot of attention in the sports world lately, starting with the announcement that Red Sox pitcher Eduardo Rodriguez was out due to myocarditis after testing positive for COVID-19. This was followed by an announcement that Big 10 football was canceled due to multiple athletes with myocarditis, then Pac-12 cancelled, as well.

The cardiac effects of COVID-19 were recognized early in the pandemic, but we did not know which types of patients would be at risk for complications, what percentage would have cardiac effects, and who needed screening. Most of the existing studies of cardiac effects are in older, hospitalized patients. Even now, we do not have any large published studies which outline cardiac findings in otherwise healthy adolescents and young adults. Studies are on-going in the professional, collegiate, and military settings. Once completed, these will be published and added to our increasing knowledge base. Our current understanding shows that any athlete returning to sports after COVID-19 should proceed with caution.

Here is what we know:

• Myocarditis is inflammation of the heart muscle. While inflamed, the heart muscle does not pump normally
• Symptoms include difficulty breathing, chest pain, and palpitations
• Exercising with myocarditis can cause sudden death
• There are multiple studies to diagnose myocarditis, including EKG, echocardiogram, cardiac MRI, and lab tests
• Many viral illnesses have potential to cause myocarditis. Coxsackie B virus is one of the more common illnesses in the community which can do this, although it is a rare complication
• Myocarditis usually resolves in 3-6 months, but some patients may have long-term side effects
• Athletes with myocarditis will miss at least an entire season of sports
• Enough college athletes had cardiac changes after COVID-19 to worry athletic officials and cancel college sports

Here is what we don’t know:

• We don’t know how common myocarditis is for children, teens, and young adults who had an asymptomatic or mild course of COVID-19
• We don’t know how long myocarditis from COVID-19 takes to resolve
• We don’t know if our current sports return recommendations are sufficient, or if they will continue to change as we learn more about this complication of COVID-19

Here are the current recommendations for sports return after COVID-19:

• All athletes with COVID-19 should stay home and isolate per CDC guidelines
• After symptoms resolve, athletes should wait at least 1-2 weeks before getting clearance from their physician to return to exercise
• The following groups of child and adolescent athletes need cardiac screening before returning to sports:
  
  • Those with symptoms severe enough to require hospitalization, including COVID-19 or MIS-C
  • Those with mild symptoms from COVID-19 which do not resolve within the typical 2 weeks
  • Those with symptoms of myocarditis, either while they were sick or when they tried to return to sports

I expect these guidelines to change as we get more data from the professional, college, and military athletes. In the meantime, parents, coaches and sports organizations should continue strategies to minimize transmission of COVID-19. If an athlete catches COVID-19, make sure they get medical clearance before returning to sports.

_sources: 

_{British Journal of Sports Medicine}

_{National Federation of State High School Associations (NFHS)}

_{American Medical Society for Sports Medicine (AMSSM)}