| Stage |
• In the Covid 19 pandemic, competitive athletes constitute, from an epidemiological perspective, a particular population due to the high environmental risk in the transmission of infections. On the other hand, if you contract the disease, it is critical to define the full recovery period for resuming your athletic activity.
• Asymptomatic non-Covid viral myocarditis is a recognized cause of sudden death, especially in individuals under 35 years of age.
• In the United States and Europe, university schools with highly competitive sports activities have developed evaluation protocols in individuals with recent Covid 19 infection, with substantial differences in the proposed strategies.
• The time to restart sporting activity is a challenging aspect with profound social implications. In our environment, renowned athletes with Covid 19 presented subclinical indicators of cardiac involvement of uncertain significance, in most cases with excellent clinical evolution.
• The role of cardiac magnetic resonance imaging (MRI), whose sensitivity in the diagnosis of myocarditis is indisputable, has not been defined.
• In conclusion, there are many aspects in which the available evidence is fragmented, and sometimes controversial.
• Research, editorials and recommendations from Scientific Societies have analyzed the problem of Covid 19 in athletes, with considerations that do not always coincide.
A recent communication ( Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection, JAMA Cardiol. 2021;6(9):1078-1087 ), which analyzed the problems posed by cardiological evaluation in athletes with a history of mild Covid, is an interesting starting point for the analysis.
| The study |
> Objective
It is an observational study that aimed to investigate:
• Global prevalence of myocarditis in athletes from 13 universities with recent mild Covid 19 infection.
• Define this prevalence by applying different diagnostic criteria for myocarditis.
• Estimate the role of MRI in presumed myocarditis due to Covid 19
> Population and design
1,597 individuals were included in which the following information was available in all cases:
• Symptoms (chest pain, dyspnea, palpitations)
• ECG, echo-doppler, troponin (with or without accompanying symptoms)
• MRI (with or without symptoms or other criteria of cardiac involvement)
In the case of MRI, the criteria of Lake Louise (2018) were used, considering the coexistence of alterations in the sequence in T1 and T2 in the segments defined by the American Heart Association as a finding of myocarditis.
The data was grouped into three categories:
• Clinical myocarditis (symptoms with/without alteration in ECG and/or Doppler ultrasound and/or troponin elevation)
• Probable subclinical myocarditis (alteration in ECG and/or Doppler ultrasound and/or elevation of troponin)
• Possible subclinical myocarditis (alteration on MRI without other findings
> Result
• 37 cases of myocarditis were diagnosed with an overall prevalence of 2.3% (0-7.6%); The prevalence by group was the following:
- Clinical myocarditis: 9
- Probable subclinical myocarditis: 8
- Possible subclinical myocarditis: 20
- The MRI showed alterations in the 37 cases in which the probable existence of myocarditis was concluded since that was the criterion adopted to affirm the diagnosis. Of them, only 17 (46%) presented symptoms, alterations in the ECG, Doppler ultrasound or elevated troponin.
- Of the total number of individuals with alterations in the ECG, Doppler ultrasound or troponin (13), only 38% (5) had accompanying symptoms.
- Of the 9 with symptoms, 5 had alterations in the ECG, Doppler ultrasound or troponin
> Comment
• Despite being protocolized prospectively, there were surely certain discrepancies in the collection and interpretation of data. Indeed, the prevalence of myocarditis, which showed marked differences between the different university centers, is indicative of this.
• In relation to MRI, the authors point out differences in hardware, software, protocols, technique, experience, and interpretation of the study. For example, it is striking that the time from Covid diagnosis to MRI was variable, with a wide dispersion of values which limits the conclusions.
• The diagnosis of myocarditis by MRI was based on the Lake Louise criteria (2018).
Now, is this isolated criterion in the absence of other manifestations validated with a firm gold standard? More importantly, what is the prognostic value of that finding?
• A new diagnostic criterion not validated by a universally accepted gold standard must then be analyzed in prognostic terms.
In this sense, in 27 of the 37 individuals with a diagnosis of myocarditis, a second MRI was available, verifying complete resolution of the images in T2 and with gadolinium (40%), and in 60% resolution in T2 but not of the gadolinium. Clearly no conclusion can be drawn from these data.
In other words, the prognostic evaluation that would allow the diagnostic criterion to be validated is fragmentary without certainty of statistical value.
| In practice |
> Cardiological evaluation
The strategy to be adopted in the athlete with mild Covid 19 in light of the available information can be summarized in the following conclusions:
• The prevalence of MRI findings as the only data without other clinical or subclinical manifestations is 1.2% according to the aforementioned study. In the absence of information regarding its prognostic relevance, it is not justified to systematically indicate MRI under these conditions in every athlete with mild Covid.
• The systematic search for subclinical manifestations (ECG, Doppler ultrasound, troponin, prevalence of 0.6%), that is, without accompanying symptoms, does not have a firm basis; It is a strategy perhaps justified in very high performance athletes with high public exposure. It should be noted that under these circumstances, troponin elevations as the only finding are associated with an excellent long-term outcome in several investigations.
• Finally, the presence of symptoms ( dyspnea, palpitations, chest pain) justifies complementary studies to clarify the condition; Even under these circumstances, the finding of minimal alterations in cardiological tests was associated with excellent clinical evolution, making an early return to usual practice feasible.
> Restart of activity
It is an eminently technical issue that concerns sports societies and specialists.
In principle, an adaptation period of two weeks with a progressive increase in activity, followed by a progressive work load, also of two weeks, is the recommendation proposed by the majority of the specialty Societies. ( Return to Sports and Exercise during the COVID19 Pandemic. American College of Sports Medicine; Infographic. Graduated return to play guidance following COVID-19 infection, Br J Sports Med October 2020 Vol 54 No 19 )
