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Return to Sports and Exercise during COVID-19 Pandemic

Written by John Steuter, MD, FACC

Over the past few months we have witnessed almost every sport be impacted by COVID-19 – March Madness and basketball seasons ceased abruptly; then hockey, track, golf and baseball/softball seasons were vastly modified. But not just team sports took a hit, personal exercise also took on a new look/feel for many individuals. With local gyms closed, people have been forced to get creative with at-home workouts.

While exercise as a whole is great, how are those individuals who have been exposed or diagnosed with COVID-19 to proceed? What implications should we as practitioners be aware of?

COVID-19 Effects on the Heart

COVID-19 induced myocardial injury is still under investigation but thus far we have seen potential relationships to:

  • Cytokine mediated cardiomyopathy
  • Demand ischemia
  • Acute coronary syndrome
  • Myocarditis from myocyte invasion from the virus

COVID-19 Related Cardiac Statistics:

  • Up to 25% of hospitalized patients infected with COVID-19 exhibit significant cardiac manifestations including left ventricular dysfunction and arrhythmias
  • Arrhythmias occur in approximately 17% of hospitalized patients
  • Heart failure and cardiogenic shock were observed in up to 33%
  • COVID-19 infected patients with hypertension, diabetes, cerebrovascular or cardiovascular disease are more likely to require hospitalization, ICU level care and die from the infection

Potential Cardiac Risk of Exercise in those with Active COVID-19

Viral induced myocarditis can result in cardiac dysfunction, arrhythmias and even death. Patients in an acute phase of COVID-19, who exercise can potentially accelerate viral replication thus increasing cellular necrosis and a proarrhythmic unstable myocardial substrate. Due to this, it is recommended that patients avoid exercise during active infection.

Return to exercise post myocarditis should be approached with caution as myocarditis accounts for 7-20% of sudden cardiac deaths (SCD) in young athletes. Given this information, those with presumed myocarditis related to COVID-19 should also avoid exercise during the acute phase of the disease.

Recommendations for Return to Exercise and Sport after COVID-19 Recovery

While there are multiple unanswered questions when it comes to prevalence of cardiac injury for anyone exposed to COVID-19 plus the short- and long-term risks, what we do know is that exercise is beneficial to a person’s cardiovascular health as well as their mental health and boosting one’s immune system.

Recreational Exerciser

Individuals who experienced only mild to moderate symptoms (were not hospitalized nor experienced concerning cardiac conditions) should be able to resume exercise at moderate intensity. Starting slow and gradually increasing intensity or duration, building up to pre-COVID-19 levels is recommended, all the while being mindful of any changes or new cardiovascular symptoms.

Individuals who had pre-existing cardiac disease prior to COVID-19 infection/exposure are potentially at a higher risk of complications and may require additional testing and risk assessment prior to a return to regular exercise levels.

Competitive Athletes & Highly Active Individuals

After the infection is no longer active and an additional 2-week post-symptom timeframe, the potential need for testing should be considered depending on the severity of COVID-19 symptoms. The COVID-19 Return-to-Play Algorithm featured below provides excellent guidance on best courses of action while keeping the safety of the athlete as the main priority.

Practical Tips for Exercise during COVID-19 Pandemic

Regular exercise is beneficial for individuals without COVID-19; however, it is important to respect current social distancing guidelines as well as common sense practices:

  • Appropriate hand hygiene
  • Cleaning exercise equipment pre- and post- use
  • Avoid touching eyes, nose and mouth
  • Bring own towel and water bottle
  • Avoid areas with high traffic and/or exposure to sweat

Guidelines and recommendations surrounding exercise and athletes exposed to and infected with COVID-19 may progress as we continue to learn more about the disease and its implications. Regardless all individuals should limit exercise if there is a concern.

For any questions regarding your patients’ cardiovascular care or if you’d like to refer a patient, please call Bryan Heart at 402-483-3333.


References:

Driggin E, Madhavan MV, Bikdeli B et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol 2020;75:2352-71.

Zhou F, Yu T, Du R et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.

Driggin E, Madhavan MV, Bikdeli B et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol 2020;75:2352-71.

Kiel RJ, Smith FE, Chason J, Khatib R, Reyes MP. Coxsackievirus B3 myocarditis in C3H/HeJ mice: description of an inbred model and the effect of exercise on virulence. Eur J Epidemiol 1989;5:348-50.

Phillips M, Robinowitz M, Higgins JR, Boran KJ, Reed T, Virmani R. Sudden cardiac death in Air Force recruits. A 20-year review. JAMA 1986;256:2696-9.

Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829-34.

Maron BJ, Haas TS, Ahluwalia A, Murphy CJ, Garberich RF. Demographics and epidemiology of sudden deaths in young competitive athletes: from the United States National Registry. Am J Med 2016;129:1170-7.

Phelan D, Kim JH, Chung EC. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol 2020.

 

steuter john

About John Steuter, MD

John Steuter, MD, is a cardiologist at Bryan Heart. Steuter is a graduate of The University of Nebraska Medical Center College of Medicine and joined Bryan Heart in 2015 after completing his residency and fellowship at The University of Nebraska Medical Center. He is certified with the American Board of Internal Medicine.

View Dr. Steuter’s physician profile

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