Returning to Exercise and Sports After COVID-19 Infection

November 4, 2020
Paul D. Thompson, MD
Paul D. Thompson, MD

Advisory Board member Dr. Paul D. Thompson offers perspective on recent guidance from the ACC on returning to sports and exercise during the COVID-19 era.

From the desk of Paul D. Thompson, MD:


I am one of 8 authors of the American College of Cardiology Exercise and Sports Cardiology Section's suggestions on managing return to play in high school, college, and older athletes after COVID-19 infection.1 These recommendations are more extensive and replace guidelines issued previously by several of the same authors.2

Both documents are based on expert opinion because there is a paucity of data on how COVID–19 affects young and old, previously healthy athletes. Both documents are also based on the concern that the cardiac abnormalities observed in sick, COVID-19 patients might also occur in athletes.

We know that vigorous exercise acutely, and transiently, increases the risk of sudden cardiac death (SCD); that myocarditis can cause such exercise-related deaths; and that COVID-19 produces increased cardiac troponin (cTn) levels in >20% of ICU hospitalized patients3 and myocarditis in a few.4 Thus, there is concern about athletes suffering exercise-related SCD on returning to vigorous activity after COVID-19 infection.

The present report provides three tables advising how to proceed with high school, adult, and Masters level athletes.1 These tables cannot be fully summarized here, but the unifying recommendation is that athletes with no or mild symptoms do not need extensive testing and can gradually proceed to full activity after an appropriate length of quarantine. Those athletes with moderate symptoms should be medically evaluated with an ECG, cTn, and echocardiogram before full activity. Those hospitalized for COVID-19 should be evaluated for ongoing myocarditis if there was evidence of cardiac involvement by cTn or myocardial imaging during their hospitalization.

The recommendations for limited testing is based on the authors’ collective experience that cardiac abnormalities in minimally symptomatic athletes are rare. There is also concern that clinicians could overreact to cardiac “abnormalities” found with extensive testing of athletes. Cardiac troponins, for example, increase after only 30 minutes of treadmill running5, and mild LGE is found in approximately 20% of healthy endurance athletes.6 Both could be mistaken for COVID-19 myocardial involvement and lead to exercise restriction and additional testing.

The present report also recommends that the managers of exercise facilities use this opportunity to update their emergency action plans. As once said by Rahm Emanuel, the former mayor of Chicago, “Never let a crisis go to waste”. Cardiopulmonary resuscitation, prompt defibrillation, and effective emergency action plans save lives.

This is a good time for all of us, including coaches and athletes, to learn or refresh CPR skills and for facilities to update their cardiac emergency action plans. President Trump will eventually be right, and COVID-19 will be controlled, but the opportunity to save someone’s life will … live on! Pun intended.