Cardiovascular Health and Returning to Triathlon after COVID-19
by Audrey Wu, MD, MPH
The COVID-19 pandemic drastically changed the world of triathlon over the past year, resulting in race cancellations, alterations in training opportunities, and for many, contracting an acute illness. Understanding of COVID-19 and its after-effects is still rapidly evolving. Many athletes who became ill with COVID-19 wish to return to training and racing, but there are few definitive guidelines to help them and their coaches chart a safe return to their previous athletic pursuits.
Brief review of acute COVID-19 infection
COVID-19 is an acute respiratory illness caused by the novel coronavirus SARS-CoV-2. Symptoms can range from a self-limited, non-specific, flu-like illness, to an extremely severe illness that can require management in intensive care, or even death. Acute heart muscle damage (myocardial inflammation) can occur, and is detected by blood tests or imaging studies such as cardiac MRI. From a clinical standpoint, manifestations of myocardial inflammation can range from asymptomatic to severe heart failure (heart muscle weakness causing symptoms such as shortness of breath, congestion, and exercise intolerance). The exact mechanism of myocardial inflammation is still undefined, and the frequency of myocardial inflammation in mild or asymptomatic cases of COVID-19, and the implications of such, are still unknown. Nonetheless, considerations of heart health are critical as coaches and athletes design a return to training
Return to play consensus guidelines
Various medical organizations have reviewed the current available data and put together consensus guidelines to help athletes navigate returning to training. Recognizing the evidence for myocardial inflammation in acutely ill patients, the American College of Cardiology’s Sports and Exercise Cardiology Section initially published guidelines in 2020 to help the athletic community return to play in a safe and thoughtful manner. Some of these COVID-19-specific recommendations are based on previous guidelines pertaining to myocarditis (an illness of acute inflammation of the heart), which recommended that athletes with diagnosed myocarditis should undergo screening with an echocardiogram (ultrasound of the heart), 24-hour Holter monitoring (continuous ECG monitor) and an exercise ECG within three to six months after the illness. These guidelines recommend that if testing is normal, then it is reasonable for the athlete to return to exercise.
In the current guidelines pertaining to COVID-19, the degree of follow-up screening recommended is proportional to the severity of symptoms during the initial illness, and whether there was any evidence of myocardial inflammation. Athletes who are asymptomatic or mildly symptomatic after COVID-19 infection in general do not need cardiovascular screening, and can resume exercise in a slow and progressive manner after 10 days from positive test (if asymptomatic) or symptom onset (if mildly symptomatic). For patients with moderate severity illness (regardless of cardiovascular symptoms), they should refrain from exercise for at least 10 days after symptom resolution, and be evaluated by a medical professional for return to play. For athletes with severe illness (hospitalized), if they had evidence for myocardial inflammation (myocarditis), they should be evaluated by a medical professional for clearance to return to training. Special consideration is given to older masters level athletes, as this age group is at higher risk for having pre-existing cardiovascular disease (including hypertension, coronary artery disease, atrial fibrillation, or diabetes). It is recommended that masters athletes with pre-existing cardiovascular conditions, or symptoms following COVD-19 infection should undergo cardiovascular screening before returning to training.
How to practically apply guidelines for your athletes
It is important to put these guidelines in context – they are based on expert opinions, using the best available current data, but as COVID-19 is such a new disease, our understanding of its effects on cardiovascular health and optimal strategies for returning to athletics is still evolving. A general guideline to follow would be that if the athlete still has any symptoms, then further medical evaluation is warranted. Tailoring of these guideline recommendations to the individual’s particular health and personal circumstances will likely also be necessary. If the athlete is asymptomatic and without any complications, exercise can generally resume in a progressive fashion, as one would after any other minor acute illness. As you and your athletes would normally, pay attention to how they are feeling – any change, even apparently small, in variables like their exercise tolerance, heart rate, or subjective shortness of breath, may warrant a follow up with their health care provider. Fitness tracker wearables may also make monitoring these vital signs easier. Especially vital after the onset of COVID-19 pandemic, our role as coaches and athletes is to be even more vigilant than usual for possible issues that might impact participation in our sport and our overall health.
Audrey Wu, MD, MPH is a Clinical Associate Professor of Cardiovascular Medicine at the University of Michigan, and a USAT level I certified triathlon coach. Follow her on Instagram @wu.audrey_tri