key: cord-0687532-vvbfuzbs authors: Hammond, Benjamin H.; Aziz, Peter F.; Phelan, Dermot title: Importance of Shared Decision Making for Return to Play After COVID-19 date: 2021-03-16 journal: Circulation DOI: 10.1161/circulationaha.120.052372 sha: 38f10196afa4b19584d716658e7de590a049d0e9 doc_id: 687532 cord_uid: vvbfuzbs nan T he potential for coronavirus disease 2019 (COVID-19)-related cardiac injury to result in major adverse events, including sudden cardiac death, has become a major source of fear for those who look after athletes. In hospitalized patients, cardiac injury is associated with worse outcomes. 1 Although the prevalence of COVID-19-related myocarditis has not been well established in athletes, such concerns have been reflected in proposed return-to-play recommendations that suggest that athletes deemed at risk of cardiac injury on the basis of their symptoms should undergo cardiac screening before returning to play. 2 Unfortunately, screening is imperfect and can lead to both false-positive and false-negative findings. There are challenges with the interpretation of biomarkers such as cardiac troponin levels, ECGs, and echocardiograms in athletes in whom exercise-induced cardiac remodeling can be misinterpreted as pathology. Small, single-centered studies using cardiac magnetic resonance in both athletes and nonathletes with mild or no symptoms who have recovered from COVID-19 have raised the specter of a high prevalence of subclinical myocarditis. 3, 4 However, although cardiac magnetic resonance is an excellent tool for diagnosing myocarditis in patients with suspected disease, its use for screening asymptomatic individuals will likely lead to overinterpretation of minor variations of parametric maps and artifact. The primary concern is for myocarditis, a known risk factor for sudden cardiac death in athletes. The current recommendation is that "athletes with probable or definite myocarditis should not participate in competitive sports while active inflammation is present." Athletes with myocarditis are generally restricted from competition for 3 to 6 months and need to undergo rigorous testing before returning to play. With widespread screening of athletes for subclinical myocarditis, cardiologists are likely to encounter patients with ambiguous test results, including mild highsensitivity troponin elevation, low-normal ventricular function, mild T1 or T2 elevation, or concern for subtle areas of late gadolinium enhancement. The clinical implications of these are particularly uncertain when seen in an asymptomatic individual who had mild symptoms when acutely infected with COVID-19. In addition to ambiguous test results, there is the question of the duration of competitive restriction in those who are considered to have subclinical myocarditis. Last, we have limited understanding of the unique risks related to restarting sports in the context of COVID-19. In the face of uncertain risk, we would advocate for the use of shared decision making (SDM) and safety plans for our athletes returning to play. Recognizing the autonomy of the athlete, SDM is an important framework for counseling patients with uncertain but low risk of adverse events about return to play. The approach involves educating the patient about the potential risks of participation in certain activities, determining the patient's priorities and values, and coming to a joint decision about whether to resume competitive sports. Although ON MY MIND FRAME OF REFERENCE sports participation in the past was decided by the physician in a binary fashion, updated guidelines from both the American College of Cardiology and the European Society of Cardiology have shifted emphasis to a more patient-centered model that supports SDM. 5 For those with residual uncertain risk, cardiologists can establish safety plans, including refraining from sports participation if symptomatic, strict medication compliance, and mandating the presence of an automated external defibrillator and cardiopulmonary resuscitation-trained bystanders during exercise. Safety plans are particularly relevant in our current situation given the unknown risks our athletes face, even when there is clear evidence of subclinical myocarditis. An environment where athletes are observed with access to automated external defibrillators and trained providers is arguably safer than situations when athletes are training alone. Although SDM is becoming a well-established framework for managing adult athletes with cardiac disease, its application to pediatric populations, who do not have legal autonomy in their own medical decision making, is less well understood. Arguments have been made in the literature to avoid the use of SDM in pediatric athletes, citing their inability to fully comprehend serious risks with feelings of immortality common to youth. Although this may be the case in some young athletes, many young athletes are capable of mature processing sufficient to engage in an SDM process. A consensus understanding of the individual's values, the perceived importance of sporting participation, and the potential risks of restriction or disqualification is further enhanced by the required involvement of an adult parent or legal guardian, with extension then to the adult coaching staff and school administration. We advocate for assessment of each individual's ability to participate with the support and direction of their parents or legal guardians. If the minor is an adolescent with sufficiently mature processing, we would engage in a discussion of risk and safety planning, as we would with an adult athlete. We ensure that the parents or legal guardians recognize their role in owning the athlete's risk as the ultimate decision makers. If the minor is deemed unable to understand all the implications of these decisions, we do not typically engage them in this discussion or offer alternatives to the recommended guidelines. In a similar manner, we do not engage in this process if the parent or legal guardian cannot understand the full implications of decisions for the minor. If the expressed interests of the parent and young athlete do not align, with the parent favoring more or less acceptance of risk than the young athlete, the discussion needs to be suspended until this is resolved between these 2 parties. The financial implications of sports participation should be addressed with emphasis that this not be used as motivation to accept more risk than otherwise might be the case. SDM in minors should be a transparent process with documentation shared with the athlete, parent or guardian, coaching staff, and school leadership as appropriate. In the case of SDM in post-COVID-19 athletes, follow-up after reengagement in sports is essential with suspension of sports eligibility if the athlete develops cardiac symptoms. We propose that cardiologists engage in SDM with their asymptomatic athlete patients with ambiguous test results to allow them the choice to participate in their sport as safely as possible. We advocate for attempting to use SDM in younger athletes with their parents, according to an assessment of mature processing. We acknowledge that this process will differ when considering restriction for a short period of time such as 3 months compared with a lifetime restriction in athletes with certain conditions. We also acknowledge the uncertainty that accompanies such a decision given the lack of clinical evidence and endorse open communication with patients to engage them in this difficult decision. Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19) Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology None.