Virginia Research Day 2021

Cardiac Pathology following COVID-19 Infection in Division 1 Athletes

Brett Brodsky, OMS-III 1 ; Austin Wood, OMS-II 1 ; Mark Rogers, DO 1,2 ; Jose Rivero, MD 3 ; Ning Cheng, MS, PhD 4 Edward Via College of Osteopathic Medicine-Virginia Campus 1 and Auburn Campus 4 ; Virginia Tech Sports Medicine 2 ; Carilion Clinic 3 ; Blacksburg, VA

Abstract

Results

Results

Sudden cardiac arrest (SCA) is the leading cause of death in competitive athletes during sports and exercise. Historical data indicate that the majority of SCA is attributable to genetic or congenital diseases of the cardiovascular system and serves as the basis for pre-participation cardiovascular (CV) screening prior to competitive athletics. Preliminary data suggest that the COVID-19 pandemic may change the risks of SCA among competitive athletes. Emerging evidence indicates potential concern for and increased risk of CV complications among COVID-19 patients, including pathology known to increase SCA risk, such as latent myocarditis and myocardial scarring. At present, data defining the results of cardiovascular screening in athletes afflicted with COVID-19 are lacking. To inform the process of resuming competitive athletics in those who have had a COVID-19 infection, while also maintaining the health and safety of athletes, there is a need for the rigorous collection of data derived from the ongoing clinical care of athletes. This year, Virginia Tech Athletics medical staff performed screening electrocardiograms (EKGs) prior to any athletic trainings when student athletes returned to campus in conjunction with their pre-participation evaluation. In addition, following a COVID-19 diagnosis, prior to clearance for return to athletic activities, we repeated the EKG and obtained serum biomarkers, Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Troponin-I, C Reactive Protein (CRP), and an echocardiogram to evaluate, and determine the prevalence for any cardiovascular pathology that may be related to COVID-19 infection, that may limit safe return to sport activity. With guidance from the NCAA Student Athlete Pre-participation Cardiovascular Screening During COVID-19 study, data were gathered from office visits from all athletes who tested positive for COVID-19 via Polymerase Chain Reaction (PCR). Pre- existing conditions, medications, body mass index (BMI), race, sex, sport, date of positive COVID-19 test, symptoms experienced, length of symptomatology, and return to activity were all included and compiled into a spreadsheet. All athletes were assigned a number and thus de-identified. There were no disqualifications. Cardiac tests were stratified into “normal” or “not normal” for EKG, Troponin -I and MRI results. The Seattle Criteria (see Figure 2) was utilized for interpretation of EKG in athletes, specifically distinguishing normal EKG alterations in athletes from abnormal EKG findings that require additional evaluation for conditions associated with SCA . An EKG was considered “normal” or “not normal” and compared to the athlete’s baseline EKG. An abnormal result in either the EKG, troponin level or echocardiogram prompted further cardiac testing with cardiac MRI. Statistical analysis based on frequencies of all categories was implemented. Methods

VT Return to Play Recommendations

35.4% Percentage of athletes who had

EKG Troponin Echo

MRI

no symptoms despite a positive COVID-19 test

95.7% 97.1% 95.7% N/A

COVID-19 Negative

Normal

No limitations to exercise

Baseline ECG

5.3 Average number of days that an athlete was symptomatic

1% 1% 2.9% 1%

Abnormal

Prior Asymptomatic Infection or Mild Illness Moderate to Severe Illness or Hospitalized COVID-19 Infection and Documented Cardiac Injury

10 Day Exercise Hiatus Myopericarditis RTP Guidelines

Table 1: Post COVID-19 Diagnostic Results. MRI testing was not performed on every athlete as baseline testing

Post-symptom Cardiac Evaluation

Conclusions

10-14 Day Exercise Hiatus Myopericarditis RTP Guidelines

References 1. Kim JH, et al. “Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play”. JAMA Cardiol. Published online October 26, 2020. doi:10.1001/jamacardio.2020. 5890. 2. Wilson MG,, et al. “Cardiorespiratory considerations for return -to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians”. Br J Sports Med 2020;54:1157 – 1161. 3. Sterakova , J, et al. “Evaluation for Myocarditis in Competitive Student Athletes Recovering From Coronavirus Disease 2019 With Cardiac Magnetic Resonance Imaging”. JAMA Cardiol. Published online January 14, 2021. doi:10.1001/jamacardio.2020.7444. 4. Drezner JA, et al. “Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’”. Br J Sports Med 2013;47:122 – 124. 5. Appleton, J, M Rogers, et al. “Detecting Clinically Significant Cardiac Abnormalities with Pre -Participation ECGs in College Athletes”. Poster presented at VCOM Annual Research Recognition Day. February 22, 2019, Blacksburg, VA We would like to acknowledge that this Study was supported by the NCAA Student Athlete Pre- participation Cardiovascular Screening During COVID-19 study, as coordinated by Massachusetts General Hospital; IRB Protocol #2020P002667. Acknowledgements ● Advanced cardiac imaging more often discovers physiological cardiovascular adaptations in the patient with post-COVID new EKG changes or underlying congenital abnormalities. ● Overall, healthy, active Division 1 student athletes are a low-risk patient population for post-COVID cardiac abnormalities. ● Clinical decision making based on symptoms during the infectious period, may drive advanced testing choices in similar populations, based on this data. ● Larger studies should continue to evaluate in this population. ● While implementing advanced imaging techniques in COVID-19 positive athletes may detect more pathology, the low occurrence rates of post COVID cardiac complications weighed against the cost of advanced diagnostics should be considered before obtaining advanced imaging. ● We suggest that a more conservative approach to management may be appropriate in the asymptomatic, minimally symptomatic, and non-hospitalized athletes as the diagnostic potential may be outweighed by cost. ● Baseline EKG prior to athletic activity as well as obtaining EKGs post-COVID may remain cost effective in our setting. ● Based on previous studies, only 4.7% of students necessitated further cardiac evaluation via an echocardiogram in the healthy athlete population and of those athletes, no student was disqualified from competition.

Comprehensive Cardiac Evaluation

Longitudinal Follow-up with serial cardiac imaging

Comprehensive Cardiac Evaluation

Figure 3: Virginia Tech Sports Medicine recommendations for return to play (RTP). Cardiac Evaluation includes CBC, CMP, CRP (C-reactive protein), hs-Tn (high sensitivity cardiac troponin), BNP (B-natriuretic peptide) ECG (electrocardiogram) and cardiac MRI (magnetic resonance imaging).

Frequency of Sports

10%

Football Lacrosse

Wrestling Baseball

2%

2%

3%

3%

41%

Track & Field Spirit W Basketball M Soccer Cross Country W Soccer M Basketball Others

4%

4%

5%

6%

10%

10%

Figure 4: Positive tests by sport

Pre-ExistingConditions

Figure 1: Top: New T wave Inversions; Bottom: Viral Myocarditis

Figure 2: Normal EKG findings in the trained athlete based upon the Seattle Criteria

3% 1%

3%

3%

None Allergy/Immunologic Pathology Asthma ADHD Hematologic Pathology HSV-1 Anxiety

7%

10%

73%

Figure 5: Pre-Existing Conditions of athletes that tested positive for COVID-19

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