The possibility of cardiac sequelae after COVID-19 is now well established. Earlier data reported a very high prevalence of cardiac involvement in infected athletes (up to 15%). (1) Dedicated return-to-play (RTP) protocols have been formulated by several sporting bodies. Data that emerged later in the pandemic however was reassuring, reporting that most athletes with COVID-19 are often asymptomatic or only have mild symptoms. Only a small proportion end up having moderate/severe symptoms in the presence or absence of active cardiac involvement after evaluation.
Striking a balance between safe return to sports practice and encouraging physical activity in previously infected children and adolescents is paramount. The pandemic has already seen a substantial number of young individuals taking on a sedentary lifestyle. An increase in screen time of more than 2h/day on weekdays has already been observed. (2) A drop in weekly minutes spent in moderate-to-vigorous physical activity has also been reported internationally. (3-4) In this latest consensus document issued by the Task Force for Childhood Health of the European Association of Preventive Cardiology, the authors give several recommendations to establish a RTP protocol for juvenile and adolescent athletes. (5)
The authors highlight that young athletes with COVID-19 are often asymptomatic or have mild symptoms. These subjects often have a benign clinical course and frequently return back to competitive sports with no sequelae. A small number of young individuals however succumb to SARS-CoV-2 infection related multisystem inflammatory syndrome (MSI-S), (6) a rare yet severe hyperimmune response in the first 6 weeks after acute infection. MSI-S has an estimated incidence of 2 per 100,000 persons younger than 18 years, 1 in 161 clinically affected individuals. (7) 10-20% of those requiring intensive care because of MSI-S have cardiac involvement (myocarditis, left ventricular dysfunction, pericarditis, malignant arrhythmias, coronary artery aneurysms) with a predominance in male individuals and patients with chronic illnesses. (8) Case mortality ranges between 0.2-2%. (9)
The consensus document recommends a gradual RTP lead by the primary care physician or team doctor in young infected athletes with no or mild symptoms. (5) Echocardiography should not be used routinely in COVID-19 infected athletes who had mild COVID-19. The risk of MSI-S is however a reality. A thorough cardiac evaluation in young athletes with moderate or severe cardiac symptoms is strongly recommended, including those with a drop in athletic performance. A baseline evaluation would include ECG, echocardiography and cardiopulmonary exercise testing. Ambulatory ECG monitoring, cardiac MRI and bloods should be considered in cases where acquired inflammatory disorders (myocarditis or pericarditis) are suspected.
Children infected with SARS-CoV2 are often asymptomatic or have only minor symptoms. Striking a balance between the long-term health benefits of exercise and safe return to competitive sports is paramount. This consensus document is a first official position paper highlighting a pragmatic RTP in juvenile and adolescent athletes. (5)
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