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Myocarditis in Athletes: Risk Factors and Relationship with Strenuous Exercise

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Abstract

Amidst the SARS-CoV-2 pandemic, myocarditis in athletes has demanded increased attention primarily because of the risk of sudden cardiac death. While most athletes who experience myocardial inflammation recover, extensive measures for screening and diagnosis are taken because of the possibility of cardiac necrosis, fibrosis, and remodeling. Several risk factors have been identified that may contribute to the development of this inflammatory response, predominantly a history of viral or bacterial upper-respiratory infections. Recent research suggests new risks specific to athletes remain in question, such as the intensity and longevity of sustained exercise, vaccination status, and genetic and epidemiologic factors. Electrocardiography, echocardiography, and cardiac magnetic resonance imaging are commonly utilized for the diagnosis of myocarditis; however, reference standards are lacking because of the variety of clinical presentations. In this article, we discuss the epidemiology, pathophysiology, and presentation of myocarditis in athletes. We then review the available literature to provide a deeper insight into the diagnostic testing methods available, with the aim of outlining the efficacy and prognostic value. Next, we discuss an algorithmic approach to patient care and treatment based upon hemodynamic stability, symptoms, and findings on testing. Finally, this article reviews the current return to play guidelines and the rationale for revisions to return-to-play protocols.

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Authors and Affiliations

  1. Department of Family Medicine, USF Morsani College of Medicine, 13330 USF Laurel Drive, Tampa, FL, 33620, USA

    Kristin J. Terry, Dusty Narducci, Byron Moran & Eric Coris

  2. Department of Orthopedics and Sports Medicine, USF Morsani College of Medicine, Tampa, FL, USA

    Kristin J. Terry, Dusty Narducci, Byron Moran & Eric Coris

  3. Department of Cardiology, USF Morsani College of Medicine, Tampa, FL, USA

    Patrick Chang

  4. USF College of Medicine, Tampa, FL, USA

    Kristin J. Terry, Dusty Narducci, Byron Moran, David Orlando, Elizabeth Botto, Austin Retzloff & Eric Coris

  5. USF Morton Plant Mease Family Medicine Residency Program, Tampa, FL, USA

    Bradford Bindas & Daniel Esan

  6. University of South Florida, Tampa, FL, USA

    Kristin J. Terry

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Kristin J. Terry, Dusty Narducci, Byron Moran, Patrick Chang, David Orlando, Bradford Bindas, Elizabeth Botto, Austin Retzlaff, Daniel Esan, and Eric Coris have no conflicts of interest that are directly relevant to the content of this article.

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Outline: DO, ED; literature review and writing: KT, DN, BM, PC, DO, BB, EB, AR, DE, EC; tables and figures: KT, EC; proof reading: KT, EC. All authors read and approved the final manuscript.

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Terry, K.J., Narducci, D., Moran, B. et al. Myocarditis in Athletes: Risk Factors and Relationship with Strenuous Exercise. Sports Med 54, 607–621 (2024). https://doi.org/10.1007/s40279-023-01969-z

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