Cardiac abnormalities in athletes after SARS-CoV-2 infection: a systematic review
J C Van Hattum, Jessica L. Spies, Sjoerd M Verwijs, Germaine C. Verwoert, R. Nils Planken, S. Matthijs Boekholdt, Maarten Groenink, Arjan Malekzadeh, Yigal M. Pinto, Arthur A.M. Wilde, H T Jørstad
Abstract
OBJECTIVES: Quantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports. DESIGN: Systematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes. DATA SOURCES: Combinations of key terms in Medline, Embase and Scopus (through 2 June 2021). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Inclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age <18 or >64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists. RESULTS: In total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%-15%, pericardial effusion 0%-58% and late gadolinium enhancement (LGE) 0%-46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%-4%) versus low scores (38%-42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities. SUMMARY/CONCLUSION: Athletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.