Lehigh County Health & Medicine Spring 2021 - 19

L C M E D S O C .O R G

permanent damage or sudden death. Diagnosing myocarditis can be a challenge, though,
as it is reliant on histology from a biopsy or
cardiac MRI. Elevated Troponin, a serum
biomarker of heart damage, is nonspecific
to myocarditis. Electrocardiogram (ECG)
changes seen in the electrical conductivity
of the heart, such as T wave inversions and
ST elevations or depressions, are also nonspecific to myocarditis. COVID-19 related
respiratory disease is also a concern and can
be associated with damage to the pulmonary
airspaces, interstitium, and pulmonary vascular interface. Thromboembolic disease can
be indicated by elevated C reactive protein
(CRP) and D-dimer, but more definitely
seen on CT chest.
Athletes who recovered at home from
COVID-19 and have no symptoms for 7
days with 10 days from symptoms' onset
should have a thorough clinical assessment
along with an ECG and Echocardiogram
(ECHO), heart ultrasound. If abnormalities
are observed, a cardiac MRI should be done
to exclude myocarditis. Cardiopulmonary
exercise testing, troponin level, or 24-hour
Holter monitor may be considered as well.
Athletes with persistent COVID-19
symptoms for 14 days since symptoms,
such as fatigue, cough, chest pain, shortness
of breath, should have a thorough clinical
assessment along with an ECG and cardiac
MRI. A chest Xray, pulmonary function tests,
CRP, D-dimer, and troponin level should
also be done. If all are normal, then proceed
to cardiopulmonary exercise testing and 24hour Holter monitor. If there are abnormal
pulmonary results (signs of pneumonia,
pulmonary embolism, or postinflammatory
bronchoconstriction), a CT chest and
cardiopulmonary exercise testing should be
done. If there are abnormal cardiac results,
training should be restricted and myocarditis
guidelines should be followed.
Athletes who were hospitalized with
COVID-19 should automatically have an
ECG, cardiac MRI, 24-hour Holter monitor,
cardiopulmonary exercise testing, CRP,
D-dimer, and troponin level. If there are
abnormal cardiac results, training should
be restricted and myocarditis guidelines
should be followed.

A suggested graduated return to play
protocol can help guide the introduction
of physical activity in a stepwise fashion. It
is important to note that if any symptoms
occur, athletes must return to the previous
stage and can only progress after a 24-hour
period of rest with no symptoms. Besides
focusing on physical wellbeing, it is also
crucial to consider the psychological
impact of prolonged recovery and deconditioning on athletes. With the support of
their physician, family, teammates, and
coaches, athletes can safely return to play
with these recommendations.

RESOURCES

Elliott N, Martin R, Heron N, et al. Infographic.
Graduated return to play guidance following
COVID-19 infection. British Journal of Sports
Medicine. 2020;54:1174-1175.
Wilson MG, Hull JH, Rogers J, et al. Cardiorespiratory
considerations for return-to-play in elite athletes after
COVID-19 infection: a practical guide for sport and
exercise medicine physicians. British Journal of Sports
Medicine. 2020;54:1157-1161.

SPRING 2021 | Lehigh County Health & Medicine 19


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Lehigh County Health & Medicine Spring 2021

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