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This year, we chose to commemorate World Heart Day (September 29th) by raising awareness about how SARS-CoV-2 impacts the younger, healthier, and physically active part of our society, thereby reminding you that even the healthiest people may be affected.

The ongoing coronavirus crisis has left countless athletes wondering how and when they might be able to continue with their regular routine. And while most professional championships were resumed after the initial lockdowns (albeit without audience), mostly because of the fact that they do an enormous part in keeping the economy from totally collapsing, we still have a lot to learn about the potential consequences of COVID-19 when talking both casual athletes and professional sportsmen.

This also begs the question of how SARS-CoV-2 impacts the younger population in general, especially the ones who tested positive, and more importantly, the ones who were unknowingly infected, but haven’t undergone any testing due to a lack of symptoms.

In one of our previous articles, we discussed the impact of COVID-19 on patients with cardiovascular diseases. And while it is true that older patients, especially those with underlying cardiovascular complications, have a higher risk of being hospitalized due to severe complications of the disease, that doesn’t mean that the virus does not present a threat to a younger and more active population.

Although virtually everyone has the same risk of contracting COVID-19 when exposed to it, athletes by definition are less likely to be afflicted with chronic health conditions like diabetes, obesity, and high blood pressure, which are comorbidities associated with more severe COVID-19.

Moreover, since moderate exercise has many positive effects on heart and lung function, these individuals generally belong to a group of patients with reduced duration and severity of COVID-19 infection.

How can COVID-19 affect physically active individuals?

Although COVID-19 is a respiratory disease, available data shows us that it also may affect other organs, notably the cardiovascular system, which is strongly associated with increased mortality. The body sometimes tends to react to the infection excessively, manifesting in a hyperinflammatory response, accountable for the majority of complications, such as blood vessel and heart muscle inflammation (vasculitis and myocarditis, respectively).

In some COVID-19 patients, heat inflammation may cause the heart muscle to work inappropriately, manifested in arrhythmias. Therefore, we cannot exclude all these types of complications in athletes who contracted COVID-19, whether they had symptoms or not. The fact that myocarditis is one of the main causes of sudden death in young athletes only makes this issue more relevant.

Other than inflammation of the heart muscle, other cardiovascular injury mechanisms should be taken in consideration as well, of which the most important include:

  • Higher probability of blood clot formation due to increased blood coagulability
  • Systemic inflammatory response syndrome
  • Decrease of oxygenated blood supplying various tissues (which may result in a heart attack)

When we talk about COVID-19 related cardiovascular complications. It’s important to mention that direct cardiac injury is reported in about 1 in every 5 patients, and that’s not including other possible issues, such as deep vein thrombosis or lung embolism, meaning that a more thorough diagnosis is needed when evaluating heart-related issues.

When it comes to evaluating their overall health, professional athletes are in a better position than people who take up sports as a part of their leisure time. This is mostly because professionals are more likely to be examined and tested more frequently, and usually are surrounded with a team of doctors specialized in sports-related medical issues.

Because COVID-19 symptoms may involve fatigue, muscle soreness and increased heart rate when resting, it is possible that they can be falsely interpreted simply as exhaustion, or even dismissed as depression or any other psychosomatic disorder.

This is why it is extremely important to take these signs and symptoms very seriously and immediately undergo testing, because late diagnosis may result in unwanted and dangerous outcomes.

How should athletes deal after COVID-19 is diagnosed?

It is a known fact that vigorous physical activity helps the coronavirus replicate more quickly, which in turn increases the chances of severe damage to the heart muscle. Just like the general population, athletes are advised to cease any heavy physical activity for at least two weeks after the symptoms have ended, during which they need to undergo additional testing, involving, but not limited to: ECG, chest X-ray (or a CT scan), cardiac MRI, stress testing, as well as checking their blood count and biochemical status, which may indicate heart tissue damage.

After the given time period has passed, and only if they are shown to have no underlying health issues, are athletes free to continue with their training, but nevertheless should take care, especially if they continue to feel exhausted in a way that is disproportionate to the physical effort involved. Of course, athletes who previously tested positive for COVID-19 are also advised to follow the same recommendations when it comes to lowering the risk of further spreading and potentially infecting people around them with SARS-CoV-2, including the use of personal protective equipment.

Follow-up examinations are important as well, since COVID-19 is a new disease, and as such, we don’t have enough information on the long-term consequences it might present, especially in a population so specific as athletes, since they are by definition young and without major pre-existing diseases in their medical history. Although the athletes who completely recovered from COVID-19 have so far shown good prognoses, doctors and other scientists still ought to collect more data in order to face this issue with a higher level of certainty.

Because COVID-19 is able to affect the cardiovascular system as a whole, it may silently progress and cause severe cardiac events at an earlier or a later stage. This means large scale non-invasive cardiac investigations are needed for all COVID-19 exposed, recovered, as well as asymptomatic part of the population who tested positive on a PCR or an antibody test.

There's no doubt that this is an extremely demanding task which needs to be delicately and precisely planned. All in all, there is much more to be learnt, and it seems reasonable that COVID-19 should be included in the cardiac history taking questionnaires, whether we talk about hospital patients, or even in general population, especially regarding healthy and active individuals taking up serious physical activities.

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