We stratify athletes that have recovered from the initial SARS-CoV‑2 infection as:
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asymptomatic or local symptoms (non-hospitalised)
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regional or systemic symptoms (non-hospitalised)
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hospitalised and no myocardial injury
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hospitalised and myocardial injury
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myocarditis
Fig. 1 shows a flowchart to assist clinicians in stratification, and suggests PPS, diagnostic and therapeutic strategies, as well as giving general sports advice.
Asymptomatic or local symptoms (non-hospitalised)
PPS of athletes after asymptomatic infection or local symptoms (Tab. 2) of COVID-19 is not indicated if a critical evaluation of signs and symptoms (by general practitioners or other qualified healthcare professionals) is negative and shows a complete recovery. The chance of cardiac sequelae is probably negligible in such individuals. Feasibility, cost considerations and burdening of local health care systems should be considered if extending the indication for PPS to low-risk individuals. However, a PPS and consultation by a (sports) cardiologist may be considered for specific groups. These groups include, but are not limited to, athletes with pre-existent cardiovascular pathology, elite athletes and athletes with impaired recovery of exercise capacity.
Regional or systemic symptoms (non-hospitalised)
PPS of patients after COVID-19 with regional or systemic symptoms (see Tab. 2 for an outline of regional and/or systemic symptoms) not requiring hospitalisation should be strongly considered. PPS includes critical evaluation of symptoms, physical examination and a 12-lead electrocardiogram (ECG). Red flags suggestive of cardiac pathology in the 12-lead ECG are outlined in Tab. 3. We emphasise that a 12-lead ECG is not the gold standard for the detection of myocarditis and other cardiovascular complication, and that a normal ECG does not rule out myocarditis in the presence of signs and symptoms suggestive of myocarditis [16, 20]. If needed, a (sport) cardiologist with experience in reading athletes’ ECGs should be consulted when differentiating between ECG changes due to cardiac adaptation to sports and exercise and ECG abnormalities suggestive of cardiac pathology [21]. Using cardiac biomarkers to screen for myocarditis has been suggested [1]. However, we advise caution when using such a screening strategy. First, most athletes do not have previously documented baseline measurements and, second, elevated biomarker levels have been demonstrated after exercise in various athletes across different sports, without clear-cut clinical implications [22].
Table 3 Red flags in ECG suggestive of cardiovascular complications If the patient has completely recovered and is asymptomatic, and the 12-lead ECG is normal, gradual resumption of sports seems warranted. In the case of complaints or ECG abnormalities suggestive of cardiovascular complications, patients should be referred to a (sports) cardiologist for further evaluation. This evaluation should include at least an exercise test and an echocardiogram, but further diagnostic tests such as Holter monitoring or cardiac magnetic resonance imaging (CMR) can be considered. In the case of persistent cardiopulmonary complaints without a cardiac substrate, ruling out a pulmonary embolism should be considered.
Hospitalised and no myocardial injury
Patients with severe COVID-19 requiring hospital or intensive care admission, without signs of myocardial damage or cardiovascular complications, should be advised to first complete a comprehensive, multidisciplinary rehabilitation programme before resuming sports and exercise [23]. After completing rehabilitation, PPS and an exercise test should be performed before the patient resumes sporting activities.
Hospitalised and myocardial injury
In the case of myocardial damage and/or newly diagnosed cardiovascular complications during hospital admission, the primary focus should be to treat the relevant pathology according to current cardiovascular guidelines [20, 24,25,26]. After discharge, comprehensive rehabilitation should be prioritised with monitoring for late cardiac complications. A return to sports should take place only after a complete cardiovascular evaluation.
Myocarditis
If SARS-CoV‑2 myocarditis is diagnosed, comprehensive clinical evaluation should take place, including CMR. In patients with myocarditis we advise intensive monitoring after discharge, and a sports restriction for at least 3–6 months, based on general myocarditis recommendations [20]. A return to sports should be evaluated by a multidisciplinary, expert team, and include input from sports cardiology and sports medicine.