key: cord-0683594-r9ahc1mk
authors: Mascia, Giuseppe; Pescetelli, Fabio; Baldari, Amedeo; Gatto, Piero; Seitun, Sara; Sartori, Paolo; Pieroni, Maurizio; Calò, Leonardo; Bona, Roberta Della; Porto, Italo
title: Interpretation of elevated high-sensitivity cardiac troponin I in elite soccer players previously infected by severe acute respiratory syndrome coronavirus 2()
date: 2020-11-23
journal: Int J Cardiol
DOI: 10.1016/j.ijcard.2020.11.039
sha: 650ddc64d946770ec5be3f0fd0765cbe5b8b6896
doc_id: 683594
cord_uid: r9ahc1mk

OBJECTIVES: To clarify the meaning of elevated cardiac troponin in elite football athletes previously infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and screened for cardiovascular involvement in the wake of competitive sport resumption. METHODS: We designed a retrospective cohort study with the collaboration of two Italian Serie A teams. Football players from both rosters (58 athletes) were systematically analysed. For every SARS-CoV-2 positive athlete, the Italian Football Federation protocol requested full blood tests including high-sensitivity cardiac troponin I (hscTnI), along with a complete cardiovascular examination. We extended the analysis to SARS-CoV-2 negative athletes. RESULTS: A total of 13/58 players (22.4%) suffered from SARS-CoV-2infection: all had a negative cardiovascular examination and 2/13 (15%) showed increased hs-cTnI values (120,8 pg/ml and 72,6 pg/ml, respectively; upper reference level 39,2 pg/ml), which did not track with inflammatory biomarkers. Regarding the 45/58 (77,6%) non infected athletes, a slight increase in hs-cTnI was observed in 2 (4.5%) subjects (values: 61 pg/ml and 75 pg/ml respectively). All hs-cTnI positive athletes (4/58, 7%) underwent cardiac magnetic resonance (CMR), that excluded any cardiac injury. CONCLUSIONS: In our retrospective study, SARS-CoV-2 infection in elite football athletes was not associated to clinical or biomarkers abnormalities. Increased hs-cTnI was rare and not significantly associated with previous SARS-COV2 infection nor with pathological findings at CMR, albeit elevated hs-cTnI was numerically more prevalent in the infected group.

assay for SARS-CoV-2 in a respiratory tract swab, which was performed weekly in the entire rosters, starting from March 1st 2020 until end June 2020. Teams' policy was to stop training for actively infected athletes, until two negative RT-PCR; then the athletes were given another two weeks rest before training resumption. All athletes at the time of the study were performing a "home training" (2-hour aerobic exercise supervised through internet by team doctors), as in-person team training was still not allowed. In COVID-19 negative athletes, we also measured hs-cTnI, performed first level clinical examination and ECG (with second-level cardiac tests planned only in case of abnormalities).

Our study protocol also called for cardiac magnetic resonance (CMR) in athletes with elevated hs-cTnI, as well as for repeated measurements of biomarkers. CMR protocol included multiplane cine imaging, short-tau inversion recovery (STIR) and late gadolinium enhancement (LGE) (see Supplementary Material). We collected anonymized data for the present study from electronic and paper medical records, including demographics, cardiovascular risk factors and co-existing conditions. (15%) had increased hs-cTnI (peak 120.8 pg/ml and 72.6 pg/ml), which did not track with inflammatory biomarkers (see Table 1 Raised cardiac markers in COVID-19 infection during the acute phase are associated with poor prognosis [3] . This elevation has several potential mechanisms, including direct cardiac myocyte infection, cytokine storm, hypoxia-mediated damage, or microvascular endothelitis [1] . The main concern for athletes with documented SARS-CoV2 infection is the risk of active or chronic myocarditis [5] . Indeed, CMR signs consistent with myocardial inflammation have been reported in up to 60% of patients recently recovered from COVID-19 hs-cTn assay can be considered a reliable "gatekeeper" for advanced investigations in athletes, as well as the role of CMR.

Our data may provide insights to physicians and politicians involved in these difficult decisions, since with our systematic screening protocol, we found no clinical or CMR evidence for myocarditis in 13 athletes with a previous, mostly asymptomatic, SARS-CoV2

infection. Increased hs-cTnI was rare and not significantly associated with previous SARS-COV2 infection nor with pathological findings at CMR, albeit elevated hs-cTnI was numerically more prevalent in the infected group. Conversely, we found persistently elevated hs-cTnI also in non-infected athletes, raising concerns on the policy of measuring this very sensitive myocardial injury biomarker in all SARS-CoV2 infected, irrespective of symptoms or signs. It should be emphasized that SARS-CoV-2 does not seem to be a cardiotropic virus.

Indeed, a less than 2% prevalence of active myocyte infection was found in 277 individuals across 22 autopsy studies [7] . Additionally in the acute phase, troponins, when elevated, do track with inflammatory and coagulation markers, suggesting non-specific cytokine-mediated cardiotoxicity [8] . On the other hand, in athletes, hs-troponins can be elevated even in absence of overt myocardial disease or injury, due to repeated exercise, especially in the young subjects [9] [10] . J o u r n a l P r e -p r o o f Figure 1 

COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options

Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection

Cardiac Troponin I Is an Independent Predictor for Mortality in Hospitalized Patients With COVID-19

Determination of 19 cardiac troponin I and T assay 99th percentile values from a common presumably healthy population

Myocarditis in Athletes Is a Challenge: Diagnosis, Risk Stratification, and Uncertainties

Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19)

Myocarditis is rare in COVID-19 autopsies:cardiovascular findings across 277 postmortem examinations

Longitudinal correlation of biomarkers of cardiac injury, inflammation, and coagulation to outcome in hospitalized COVID-19 patients

Cardiac Biomarker Release After Exercise in Healthy Children and Adolescents: A Systematic Review and Meta-Analysis

Effect of Training Load on Post-Exercise Cardiac Troponin T Elevations in Young Soccer Players

Acknowledgements: no sources of support.