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Long Haul COVID-19: “JAMA: Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play”

See long-haul COVID-19.

This applies directly to me and other highly active people. I’ve monitored my heart rate during exercise for 20 years, including the past 7 months. While I’ve been unable to excercise for many days in the past 7 months, those times I have done so, I have seen normal heart rate for the same power output—no deviation. Other than the +15 bpm or so increase from detraining, but that is a yearly cycle, and also normal. But none of that means I am necessarily free from cardiac sequelae.

A cardiologist tells me the following about how to check for cardiac issues post-COVID, but it’s complicated for an athlete like me:

1.  Adequate history and physical exam (good lick with that)
2. Resting ECG (not critical and non-specific, but may helpful in suggesting underlying cardiac dysfunction if changes from prior ECGs.
3.  Echocardiogram to look for evidence or abnormal cardiac chamber enlargement, abnormal wall motion, systolic (contraction) or diastolic (relaxation) function. One issue here for you as an aerobic master athlete, you could have enlarged cardiac chambers and increased wall thickness, so-called “athlete’s heart”. Those changes usually resolve after 3-6 months of cessation of training. With you having been ill for several months, you wouldn’t know if enlargement (if present) was due to training or intrinsic dysfunction
4.  Occasionally additional information may be obtained with cardiac magnetic resonance imaging (CMR). The basic thing sought with this modality is evidence of scarring in the heart muscle. 

Below, the article is a good start, but only a very basic start—it does not address other critical factors, like overwhelming Epstein Barr Virus infections following COVID, or in my case, the development of Hashimoto’s Thyroiditis (an auto-immune disease and AI diseases are increasing being seen as part of long-haul COVID) along with what I deem “vagal nerve disfunction”.

JAMA: Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play

Oct 26, 2020

Importance  Cardiac injury with attendant negative prognostic implications is common among patients hospitalized with coronavirus disease 2019 (COVID-19) infection. Whether cardiac injury, including myocarditis, also occurs with asymptomatic or mild-severity COVID-19 infection is uncertain. There is an ongoing concern about COVID-19–associated cardiac pathology among athletes because myocarditis is an important cause of sudden cardiac death during exercise.

Observations  Prior to relaxation of stay-at-home orders in the US, the American College of Cardiology’s Sports and Exercise Cardiology Section endorsed empirical consensus recommendations advising a conservative return-to-play approach, including cardiac risk stratification, for athletes in competitive sports who have recovered from COVID-19. Emerging observational data coupled with widely publicized reports of athletes in competitive sports with reported COVID-19–associated cardiac pathology suggest that myocardial injury may occur in cases of COVID-19 that are asymptomatic and of mild severity. In the absence of definitive data, there is ongoing uncertainty about the optimal approach to cardiovascular risk stratification of athletes in competitive sports following COVID-19 infection.

...Multicenter registry data documenting cardiovascular outcomes among athletes in competitive sports who have recovered from COVID-19 are currently being collected to determine the prevalence, severity, and clinical relevance of COVID-19–associated cardiac pathology and efficacy of targeted cardiovascular risk stratification...

...Reports of presumptive myocarditis among several athletes with high profiles have magnified concerns about COVID-19 CV sequelae in athletes.6,7 Our combined experience suggests that most athletes with COVID-19 are asymptomatic to mildly ill, and to date, RTP risk stratification has yielded few cases of relevant cardiac pathology. However, we underscore that these observations may not reflect the true prevalence and attendant prognosis of COVID-19 CV involvement in athletes.

If you are a serious athlete, adaptations in your heart muscle make diagnosing heart issues much more challenging:

At present, there is no widely accepted definition of what constitutes clinically relevant myocardial injury secondary to COVID-19 infection among athletes in competitive sports...

Similarly, benign consequences of longer-term exercise training, including mild reductions in left ventricular ejection fraction21 and nonischemic myocardial fibrosis, may further complicate the diagnosis of cardiac injury secondary to COVID-19...

...normal hs-cTn reference ranges for athletes, stratified by age and sex, do not exist, which can lead to clinical dilemmas in interpreting borderline or mildly elevated values...

Lack of reference data makes it difficult to know if the prevalance of post-COVID myocardial inflammation in athletes:

... more recent observational data set included only young athletes in competitive sports. In this single-center, cross-sectional case series of athletes in US collegiate sports who were asymptomatic or mildly ill (N = 26) with normal electrocardiogram (ECG) results, hs-cTn levels, and echocardiography results, the authors reported a 15% prevalence (all men; 2 with no symptoms) of CMR findings meeting criteria for myocardial inflammation27 and 46% prevalence of mild LGE without evidence of active inflammation.9 However, the absence of an appropriate control population, normative CMR data among young athletes, and details pertaining to study methods render the clinical implementation of these findings uncertain.

...Myocarditis preceded by a viral infection30,31 is a common causative mechanism of sudden cardiac death in athletes32 and military personnel33 and should be considered in the differential diagnosis of athletes with persistent symptoms and prior COVID-19 infection. Symptoms including chest pain, exercise intolerance, ventricular arrhythmias, and abnormal findings on basic testing...

Whether All Athletes With Positive Test Results for COVID-19 Need CMR Imaging

At present, there are insufficient data to support CMR-based screening of all athletes with suspected or confirmed prior COVID-19 infection...

The Appropriate RTP Approach for Masters-Level Athletes With COVID-19

Aging athletes harbor traditional CV risk factors and established forms of disease, and athletes at the masters level constitute most patients seen in sports cardiology clinics. At present, CV sequelae and outcomes among athletes in masters-level endurance sports with prior COVID-19 infection remain unknown. Taking into account the logistics required for widespread CV screening of athletes at the masters level, coupled with the anticipated low risk of clinically significant cardiac injury in the context of mild infection, routine RTP CV assessment in this population is not recommended. However, masters athletes older than 65 years, particularly those with preexisting CV conditions (eg, hypertension, coronary artery disease, atrial fibrillation, diabetes) and those with persistent symptoms may benefit from risk stratification. Similarly, those with moderate to severe prior COVID-19 infection should be evaluated by a cardiologist for consideration of RTP risk stratification. An approach to individualized RTP risk stratification for athletes at the masters level is presented in Figure 2.

My symptoms lasted about 20 days initially, and here I am 7 months later with months of trouble. But it seems that I haven’t died yet, and testing is complicated and dubious at best due to many unknown. I *did* use a “gradually escalating” resumption of training, but it took me down so hard in mid-June (about 6 weeks after the initial 20 day phase), I could hardly walk for a week.

... In athletes infected with COVID-19 with mild symptoms that completely resolve during 10 days of self-isolation after a positive test result or symptom onset, RTP CV risk stratification appears to be low yield. Accordingly, we do not advocate CV RTP risk stratification among athletes in competitive sports with mild, self-limited disease. However, CV testing should be considered on an individualized basis for athletes with protracted symptoms (≥10 days). Among all athletes with COVID-19, regardless of symptom severity, a gradually escalating approach to training is recommended. The optimal duration of this process remains to be defined and will likely vary. Severity and duration of infection coupled with baseline fitness levels and short-term athletic goals may be used to develop individualized plans. If symptoms develop, comprehensive CV evaluation, as recommended following moderate or severe COVID-19 infection, is recommended.


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