Expert opinion on resumption of exercise after Covid 19 Infection

COVID-19 is associated with significant mortality and morbidity, including adverse cardiovascular sequelae. There are no guidelines available for resumption of recreational and competitive sports after Covid 19 Infection.

American College of Cardiology's Sports & Exercise Cardiology Council, with input from national leaders in sports cardiology has released a consensus expert opinion clinical framework on return to play in the era of COVID-19.

Dr Dermot Phelan and associates have formulated the guidelines which have been published in the Journal of American Medical Association.

The guidelines will provide guidance as to when competitive athletes and highly active individuals who have been infected with COVID-19 and recovered are medically appropriate to return to play.

Unfortunately there are limited data establishing the epidemiologic and clinical metrics required to facilitate this process. Specifically, the prevalence of asymptomatic COVID-19 cases in the community, the prevalence of cardiac injury among nonhospitalized individuals with COVID-19, and long-term outcomes attributable to COVID-19 cardiac injury remain unknown. Moreover evidenced-based recommendations for return-to-play guidelines are currently limited and clearly subject to change as further data are obtained in concert with improved COVID-19 case identification.

Considering all the limitations the researchers have recommended an emphasis on the temporal progression of confirmed infection and have incorporated time-based benchmarks in their recommendations.

Key recommendations are-

1.For athletes who remain asymptomatic and are negative for COVID-19, return to exercise training is permissible without additional testing. However, asymptomatic athletes who test positive for COVID-19 antigen (active infection) should refrain from exercise training for at least 2 weeks from the date of positive test result and follow strict isolation guidelines.

2. If athletes remain asymptomatic, slow resumption of activity should be guided under direction from their medical professional. For those asymptomatic individuals with detected COVID-19 antibodies in response to prior infection, it is recommended to have similar evaluation as the asymptomatic athlete with positive COVID-19 test results, and cardiac testing should be considered if there is concern for cardiac involvement.

3 For athletes who are positive for COVID-19 and develop mild or moderate symptoms, we recommend a minimum of 2 weeks' cessation of any exercise training from symptom resolution. Whether the increased risk of myocardial injury in hospitalized patients with COVID-19 translates to mildly ill nonhospitalized patients is unknown1 but underscores the need to carefully consider the possibility of cardiac injury among nonhospitalized patients with COVID-19.

4. For recovered individuals ready to resume training after temporal restrictions, we recommend a careful, clinical cardiovascular evaluation in combination with cardiac biomarkers and imaging. Further adjunctive testing with cardiac magnetic resonance imaging, exercise testing, or ambulatory rhythm monitoring should be based on the clinical course and initial testing. With no symptoms and no objective evidence of cardiac involvement, a return-to-exercise training with close clinical follow-up would be reasonable. If testing suggests cardiac involvement, return to play should be based on myocarditis return-to-play guidelines.3

5.Previously hospitalized or more severely ill patients with COVID-19 represent a higher-risk cohort. Acknowledging that myocarditis might not represent the underlying etiology for all hospitalized patients with COVID-19–associated cardiac injury, we recommend following myocarditis return-to-play recommendations.

6.For those who were hospitalized with COVID-19 but whose cardiac biomarkers and imaging studies were normal, we recommend a minimum of 2 weeks' rest after symptom resolution before they undergo careful clinical cardiovascular evaluation with consideration of repeated cardiac testing, followed by a graded resumption of exercise.

The recommendations regarding resumption of intense exercise training and competition are difficult to make.It may require careful consideration of the severity of prior infection and the likelihood of cardiovascular involvement.

The approach is conservative and subject to change till such time that prevalence of cardiac injury in nonhospitalized athletes is better defined.

Various important public health measures like widespread antigen testing, the development and dissemination of antibody testing, and ultimately vaccination to prevent disease need to be instituted coupled with rigorous surveillance to ensure the safe global resurrection of a thriving sport and athletic industry.

The researchers emphasized the critical need for widespread antigen testing, the development and dissemination of antibody testing, and ultimately vaccination to prevent infectious diseases. These important public health objectives coupled with rigorous surveillance of long-term clinical outcomes among athletes will be required to ensure the safe global resurrection of a thriving sport and athletic industry.

For further reference log on to: doi:10.1001/jamacardio.2020.2136