Gradual return to exercise after COVID-19 requires ‘cautious approach’
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In patients with COVID-19, the severity of the disease and the possibility of CV involvement should be taken into account when considering a return to intense exercise training and competition.
Myocyte invasion caused by SARS-CoV-2 can lead to myocarditis, which could then result in arrhythmias, cardiac dysfunction and death, Matthew W. Martinez, MD, FACC, director of sports cardiology and co-director of the Chanin T. Mast Center for Hypertrophic Cardiomyopathy at Atlantic Health System – Morristown Medical Center in New Jersey, and colleagues wrote in a viewpoint published in JAMA Cardiology.
“If you exercise when you have myocarditis, there is an increase in risk of disease progression, and exercise causes increased viral replication and progression of heart damage in those with active myocarditis,” Martinez, a Cardiology Today Editorial Board Member, told Healio. “Because of the known risk for adverse events including cardiac arrest in those with active myocarditis, a cautious approach to returning to exercise for highly active people and competitive athletes who are positive for COVID-19 is required.”
Testing in certain patients
A return to exercise training can be done without additional testing in athletes who are asymptomatic and are COVID-19-negative, the authors wrote. If athletes are asymptomatic and test positive for the COVID-19 antigen, they should abstain from exercise for at least 2 weeks from the positive test and isolate themselves. Activity can resume slowly if athletes remain asymptomatic. Athletes with detected COVID-19 antibodies from a previous infection and no symptoms should undergo cardiac testing if cardiac involvement is suspected, similar to those who are asymptomatic and tested positive for COVID-19.
“A conservative approach for now is recommended, which can be tailored based on the patient symptoms, type of sport/activity they are wishing to return to and clinical assessment,” Martinez said in an interview.
Exercise should be stopped for at least 2 weeks after symptom resolution in athletes who tested positive for COVID-19 and have mild to moderate symptoms. Once these athletes are ready to resume exercise, a clinical CV evaluation with imaging and cardiac biomarkers is recommended. Athletes without symptoms and no objective evidence of cardiac involvement can return to exercise with clinical follow-up. Returning to exercise for athletes with cardiac involvement should be based on return-to-play guidelines for myocarditis, which is based on the absence of biomarkers indicative of inflammation, normal ventricular function and no inducible arrhythmias.
A higher-risk group in athletes with COVID-19 are those who were severely ill or were previously hospitalized, according to the viewpoint. Athletes who were hospitalized with COVID-19 but had normal imaging studies and cardiac biomarkers should rest for at least 2 weeks after symptoms resolve. After that, athletes should undergo clinical CV evaluation including cardiac testing while gradually resuming exercise.
“Understanding of COVID-19 is evolving quickly, and the incidence of cardiac injury in nonhospitalized patients remains unknown,” Martinez told Healio. “As more data become available, our recommendations may change.”
Social distancing when exercising
The American College of Cardiology also published an expert analysis on its website, in which Martinez and co-authors focus on the importance of these recommendations in addition to adhering to social distancing guidelines when resuming exercise.
“It is important to respect current social distancing guidelines, which includes avoiding exercising in groups,” Martinez told Healio. “Maintaining 2 m distance may not be enough when exercising. Due to expansion of the particle spread, those further away (behind you) may be at risk of exposure. Consider continuing with 4 m to 5 m if walking, 10 m if running and 20 m if cycling.”
Athletes should keep social distancing in mind as gyms reopen, Martinez told Healio.
“Athletes should take ownership of maintaining adequate distancing, hand-washing and cleaning equipment,” he said. “Clean equipment before and after use. Athletes should try to exercise in isolation outdoors or in well-ventilated rooms while avoiding touching the eyes, nose and mouth. As gyms are beginning to open, common sense practices should be employed such as bringing your own towel, method of hydration — avoid communal faucets and water fountains/coolers — and avoid areas with high traffic or exposure to sweat.”
Despite the recommendations detailed in the viewpoint, more research is needed to formulate more detailed guidelines, he said.
“We need more data about asymptomatic disease prevalence, how often it occurs, how many develop sequelae including cardiac injury and follow-up in those who test positive for immediate and longitudinal outcomes, how many have cardiac injury, does it recover, what treatments were employed,” Martinez told Healio. “We need more guidance on how often repeat testing is needed and how often those who test positive develop antibodies and what that immunity means.” – by Darlene Dobkowski
References:
Emery MS, et al. Exercise and athletics in the COVID-19 pandemic era. American College of Cardiology. May 14, 2020. Available at: www.acc.org/latest-in-cardiology/articles/2020/05/13/12/53/exercise-and-athletics-in-the-covid-19-pandemic-era. Accessed May 19, 2020.
Phelan D, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2020.2136.
For more information:
Matthew W. Martinez, MD, FACC, can be reached at matthewwmartinez@gmail.com.
Disclosures: Martinez reports he is a cardiologist for Major League Soccer and the New York Jets and consults for the NBA and some NCAA schools. Please see the study for all other authors’ relevant financial disclosures.
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Emery MS, et al. Exercise and athletics in the COVID-19 pandemic era. American College of Cardiology. May 14, 2020. Available at: www.acc.org/latest-in-cardiology/articles/2020/05/13/12/53/exercise-and-athletics-in-the-covid-19-pandemic-era. Accessed May 19, 2020.
Phelan D, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2020.2136.
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