A guide to returning to physical activity after COVID-19, according to the American College of Cardiology

Last week, the American College of Cardiology (ACC) released clinical guidance on the cardiovascular consequences of COVID-19. The consensus document provided practitioners with a framework to understand and manage the most common cardiac sequelae of the disease.

As Infobae published last Thursday, the so-called “expert consensus decision pathway for the evaluation and management of adults with consequences The study analyzed myocarditis and other types of myocardial involvement resulting from SARS-CoV-2 infection, patient-centered approaches to prolonged COVID and guidance on resuming exercise after overcoming the disease. The ACC published its clinical guideline in the Journal of the American College of Cardiology.

“This document attempts to provide key recommendations on how to evaluate and manage adults with these conditions, including guidance for safe return to play for competitive and non-competitive athletes,” said Ty Gluckman, co-chair of the expert consensus decision pathway.

Experts defined prolonged COVID or PASC (Post Acute Sequelae of Coronavirus SARS-CoV-2, i.e. long-term sequelae of SARS-CoV-2 infection) as “a constellation of new, recurrent or persistent health problems that people experience 4 or more weeks after infection with SARS-CoV-2. Patients with this condition commonly experience a wide range of symptoms, including fatigue, cognitive dysfunction, sleep disorders, and exercise intolerance. The reported symptoms cover almost all organ systems, with different impacts on quality of life.”

One of them is myocarditis, or inflammation of the heart. This is a condition defined by the presence of cardiac symptoms (chest pain, shortness of breath, palpitations), elevated cardiac troponin (biomarker of heart injury) and abnormal electrocardiogram (ECG), cardiac imaging (echocardiogram, cardiac MRI) and/or abnormal cardiac biopsy findings.

American experts noted that, although rare, COVID-19 myocarditis is most often seen in men. “Because myocarditis is associated with an increased risk of heart complications, a proactive management plan must be implemented to care for these people. For patients with mild or moderate forms of myocarditis, hospitalization is recommended to closely monitor the worsening of symptoms, while undergoing follow-up tests and treatment. Ideally, patients with severe myocarditis should be hospitalized in centers with experience in advanced heart failure, mechanical circulatory support and other advanced therapies,” the experts recommended.

As for people who regularly engage in intense physical activity, they warned that “heart lesions were observed among some patients hospitalized with COVID-19” and there was “uncertainty about the cardiovascular sequelae after a mild illness.” This questioned the way to return to sports. “Subsequent data from large records have demonstrated a low overall prevalence of clinical myocarditis, without an increase in the rate of adverse cardiac events. Based on this, an updated guide is provided with an evidence-based practical framework to guide the resumption of athletics and intense physical training,” they explained.

Given this, the medical criterion for “athletes recovering from COVID-19 with continuous cardiopulmonary symptoms (chest pain, shortness of breath, palpitations, dizziness) or those requiring hospitalization with increased suspicion of cardiac involvement, should be further evaluated with triad tests: an ECG (electrocardiogram), cardiac troponin measurement and an echocardiogram”. Of this group, those who presented “abnormal test results” should undergo “further evaluation with cardiac magnetic resonance imaging (cardiac MRI). People diagnosed with clinical myocarditis should refrain from exercising for three to six months,” they warned.

In contrast, “heart tests are not recommended for people who are asymptomatic after COVID-19 infection,” although “people should refrain from training for three days to ensure that symptoms do not develop.” But those who have “mild or moderate non-cardiopulmonary symptoms (fever, lethargy, muscle aches), training can resume after the resolution of the symptoms. For those with remote infection (≥ three months) without ongoing cardiopulmonary symptoms, a gradual increase in exercise is recommended without the need for cardiac tests,” they said.

Considering that the presence of myocarditis in competitive athletes has been “low”, the authors of the paper noted that these recommendations can be applied to young athletes of an average age of 14 years “together with adults who are enthusiastic about recreational exercise. However, future studies are needed to better understand how long heart abnormalities persist after COVID-19 infection and the role of physical training in prolonged COVID.”

“In addition, a graduated RTP (return to sport) regimen should be emphasized in all people with a history of COVID-19 to ensure close monitoring of new cardiopulmonary symptoms,” ACC specialists said. “For those who participate in organized competitive sports, graduated exercise programs must be individualized and implemented, with the support of athletic trainers and primary care sports medicine physicians,” they clarified.

Meanwhile, “for most people participating in high-level recreational athletics, a graduated return to exercise program equates to more qualitative gradual increases in effort. This remains a key point of emphasis, as many high-level recreational exercise enthusiasts do not have immediate access to cardiac tests and sports cardiology referrals, regardless of the severity of the symptoms,” they warned.

For athletes who have cardiopulmonary symptoms, “the initial evaluation should ideally be with an ECG, cTn (cardiac troponin biomarker) and an echocardiogram. The presence of abnormal findings with the triad test or the persistence of cardiopulmonary symptoms (specifically chest pain or tightness, palpitations or syncope) after the initial test suggests that further evaluation with CMR (cardiac magnetic resonance imaging) should be performed.”

“The maximum effort test can be a useful supplement in cases of persistent cardiopulmonary symptoms, only after myocarditis with CMR has been excluded. Based on the low prevalence of myocarditis observed in competitive athletes with COVID-19, it is also reasonable to apply these recommendations to high school athletes (age ≥14-15 years) along with masters-level recreational exercise enthusiasts,” they concluded.

Athletes who have a history of COVID-19 and cardiopulmonary symptoms, “the length of time since symptom resolution and the athlete's current clinical status should dictate the approach,” they said, detailing: “If less than 1 month has elapsed since the resolution of cardiopulmonary symptoms, tests should be performed for triad. If it has been >3 months since the resolution of cardiopulmonary symptoms and there are no limitations to exercise, further heart tests may not be required. The rationale for this is derived from prior counseling that recommends avoiding exercise for at least 3 months in cases of confirmed myocarditis.”

On the other hand, if it has been 1 to 3 months since the person stopped having cardiopulmonary symptoms, in the case of athletes who “have returned to training on their own without limitation of exercise, it is reasonable to allow continuous training without additional cardiac evaluation. This decision must be individualized and based on clinical judgment, informed by the type and severity of previous symptoms. Factors that warrant further cardiac evaluation include previous worrying cardiopulmonary symptoms (e.g., syncope, palpitations due to sustained exertion and/or chest tightness or exertional dyspnea).”

Experts estimated that more and more people who practice physical activity and do not have symptoms after having had COVID-19 want to be evaluated to return to their usual practices. “Regardless of the amount of time that has passed since infection, athletes who have remained asymptomatic or who have had non-cardiopulmonary symptoms and are exercising without limitation do not require further heart tests,” they concluded.

KEEP READING