key: cord-0694813-z5o83iyt authors: Costello, Ben T; Climie, Rachel E; Wright, Leah; Janssens, Kristel; Mitchell, Amy; Wallace, Imogen; Lindqvist, Anniina; Foulkes, Steve; Paratz, Elizabeth D; Flannery, Michael D; Saner, Nicholas; Griffin, David; Green, Danny J; Cowie, Brian; Howden, Erin H; Garnham, Andrew; La Gerche, Andre title: Athletes with mild COVID-19 illness demonstrate subtle imaging abnormalities without exercise impairment or arrhythmias date: 2021-10-20 journal: Eur J Prev Cardiol DOI: 10.1093/eurjpc/zwab166 sha: 50204af11cdda30be46330ca7a9cba211c233f48 doc_id: 694813 cord_uid: z5o83iyt nan Coronavirus disease-19 (COVID-19) has been associated with cardiac pathology raising the possibility of serious cardiac arrhythmias among athletes returning to competition post infection. [1] [2] [3] Several studies have assessed cardiac function and structure in athletes post-COVID-19 infection but have been challenged by selection bias, lack of an appropriate control group and none have included comprehensive imaging, exercise testing, and clinical electrophysiology. 2, [4] [5] [6] [7] We recruited every player from a squad of professional basketballers involved in a 'super-spreader' event that lead to a majority being infected with COVID-19 following a single training session in Melbourne, Australia. We compared those athletes who tested positive to COVID-19 by polymerase chain reaction diagnostic testing (16 athletes) to athletes who (i) tested negative and (ii) had no symptoms suggestive of COVID-19 infection (n = 8). Our hypothesis was that electrocardiogram, biochemical, and imaging variants are common in highly trained athletes and would not be more prevalent in athletes recovering from COVID-19 than non-infected teammates. Comprehensive testing was performed between 10 and 21 days from the time of testing positive to COVID-19. Testing involved clinical assessment, biochemistry (including cardiac troponin I and B-type natriuretic peptide), 12-lead electrocardiography, 24-h Holter monitoring, cardiopulmonary exercise testing, echocardiography, studies of flow mediated dilation, and cardiac magnetic resonance imaging (CMR). Regional myocardial fibrosis was visually identified by delayed gadolinium enhancement (DGE), T1 mapping was analysed using a mid-wall region of the septum and three T2 measurements were analysed; mid septum, global left ventricle, and the highest T2 time at any site. A comprehensive description of all methods is included as supplementary content. COVID-19 positive athletes had mild (75%) or moderate (25%) symptoms including ageusia/anosmia, fevers, myalgias, and cough persisting for a maximum of 6 days. One COVID-19 positive athlete had a known history of hypertrophic cardiomyopathy and one had been evaluated for ventricular ectopics several years prior. COVID-19 positive athletes were similar in age, gender, biochemical markers of cardiac damage, exercise capacity, and ventilatory efficiency when compared with COVID-19 negative athletes. Similarly, there were no differences in electrocardiographic measures, arrhythmias, or ventricular pauses, nor any differences in cardiac or vascular imaging markers (see Table 1 ). Of note, one COVID-19 positive athlete with hypertrophic cardiomyopathy had a mildly elevated troponin, infero-lateral T-wave inversion, and minor DGE. One other COVID-19 positive athlete had evidence of DGE comprising a very small patch in the mid lateral wall (athlete 6 in Figure 1 ) and one COVID-19 negative athlete had very small patches of mid septal enhancement (athlete 3 Figure 1 ). In both cases the troponin, T1 and T2 mapping were normal and there were no arrhythmias on a 24-h Holter study. Native, post-contrast and T2 mapping were not different between groups. Pericardial enhancement and/or trivial pericardial effusions were frequently observed and were equally represented between groups (see Figure 1 ). Apart from the athlete with hypertrophic cardiomyopathy, very minor elevations in troponin were observed in three additional athletes (two COVID-19 positive and one COVID-19 negative, P = 0.70). In these athletes, there were no other abnormalities on imaging or exercise testing. At 6-month post-assessment, all athletes continue training and competition without any symptoms or clinical events. With the goal of assessing the health outcomes in professional athletes returning to sport after COVID-19 infection, this cohort study is unique in the completeness of recruitment and the comprehensiveness of the measures. By enrolling all athletes from a single team at the start of a pandemic outbreak (with extremely low chance of prior infection), it was possible to eliminate selection bias. Prior studies may have been compromised by a tendency to recruit athletes with symptoms sufficient to warrant testing. Furthermore, the comparison with appropriate control athletes provides important qualification of the assumption that all abnormalities in COVID-19 athletes are significant. For example, troponin elevations are considered pathological in most settings, but are prevalent amongst training athletes, including basketballers. 8 Similarly, the finding of ventricular ectopics, increases in CMR mapping values or pericardial abnormalities may have been considered significant if it were not for the comparison with an appropriate control group. Studies to date have tended to focus on cardiac imaging abnormalities without the context of impact on symptoms, exercise capacity, or electrophysiological abnormalities. 2, 4, 5, 7, 9 In comparing athletes with mild COVID-19 illness to a group of uninfected athletes, we observed no differences in imaging parameters and a lack of association with abnormalities on biochemistry, exercise testing or electrophysiology. The findings from these detailed examinations add to the reassurance provided from larger but less comprehensive studies of athletes recovering from COVID-19 illness. 6, 7 In conclusion, abnormalities can be observed in athletes' biomarkers, imaging, and electrophysiology, regardless of COVID-19 infection. These are not associated with persisting symptoms, exercise intolerance, or clinical sequalae. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19) High prevalence of pericardial involvement in college student athletes recovering from COVID-19 Exercise in the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) era: a question and answer session with the experts endorsed by the section of Sports Cardiology & Exercise of the European Association of Preventive Cardiology (EAPC) Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection Outcomes Registry for Cardiac Conditions in Athletes Investigators. SARS-CoV-2 cardiac involvement in young competitive athletes Evaluation for myocarditis in competitive student athletes recovering from coronavirus disease 2019 with cardiac magnetic resonance imaging Cardiac troponin I release after a basketball match in elite, amateur and junior players Screening of potential cardiac involvement in competitive athletes recovering from COVID-19: an expert consensus statement Conflict of interest: none declared. The data underlying this article will be shared on reasonable request to the corresponding author.