The respiratory system and the heart are focal points of the response, Glembotski said. There’s also evidence that the SARS-CoV-2 virus that causes COVID-19 can directly infect the heart and cause arrhythmias and, in some cases, contribute to symptoms that mimic a myocardial infarction, or heart attack, Glembotski said.
“There have been cases of some brain problems, a few cases of stroke and brain fog where people report that they have a general feeling that their thinking is not as good as it was before COVID-19. Among the things that are so worrisome about SARS-CoV-2 is that it has such widespread effects in the body, and the spectrum of its effects are so different from one person to the next,” he said.
“Most of what we are learning about COVID-19 is from research emerging currently, so not a lot is known. There’s more to be found out.”
Avoiding sudden cardiac death in young athletes
Erickson said the aim of his recommendation for athletes is to prevent sudden cardiac death and to prevent long-term damage from COVID-19. The evidence may not be conclusive, but when the risk is death, it’s better to do more than less, he said.
His advice comes from emerging research such as the Ohio study that is not definitive yet suggests an association between COVID-19 and cardiac problems, chiefly myocarditis.
Myocarditis may cause shortness of breath and symptoms of congestive heart failure. It can cause arrhythmia, which is an irregular heartbeat that reduces the heart’s ability to pump blood and cause someone to collapse and even die.
Erickson is the first to say the research to date is not conclusive, but he doesn’t want to take chances. Myocarditis is of particular concern in athletes because it is associated with a higher-than-average rate of sudden cardiac death.
It’s doubtful that athletes have more of a tendency for myocarditis than the regular population, but the stress of constant exercise means the myocarditis can manifest more severely in them.
“Somebody that is not participating in vigorous cardiovascular exercise doesn’t need to be screened,” Erickson said.
“But anyone, including your middle-aged marathon runner, absolutely we think they need to be screened after they recover from COVID before they go back to vigorous exercise because we don’t want them to damage their heart or have sudden cardiac death.”
Pedrotty agrees with Erickson’s recommendation to do routine cardiac screening on high-functioning athletes of all ages who have been sick with COVID-19 for three days or more.
She might add testing for c-reactive protein in addition to looking for troponin in a blood test, she said, because c-reactive protein is a measure of inflammation.
Heart damage is unlikely in someone who has tested positive for COVID-19 yet had no symptoms, nor is it likely in anyone who was sick with the virus for fewer than three days, Erickson said.
Those individuals do not need cardiac screenings, he said.
Myocarditis a big concern for young athletes
Myocarditis as a result of viral infections like HIV and Coxsackie B virus, while rare, has long been a concern for cardiologists. The risk of myocarditis is one of the reasons the general recommendation for sports medicine is that no one with a fever of 101.5 or more should exercise, Erickson said.
“The risk of playing is that the virus could spread to the heart and you could have myocarditis,” he said
The COVID-19 pandemic has heightened the concern over myocarditis because the viral disease is so new and its long-term effects remain uncertain.
“We don’t see a lot of myocarditis in general. But the reason it’s particularly important in athletes and exercise is that it’s one of the more common causes of sudden death in young athletes,” said Dr. R. Todd Hurst, a cardiologist with the Banner University Medicine Heart Institute.
“Maybe up to 20% of sudden death in a young athlete is subsequently diagnosed as myocarditis. When we have a patient that has been diagnosed with myocarditis, the recommendation is that they not participate in strenuous exercise for three to six months.”
Various early studies of COVID-19 patients have shown evidence of myocardial damage in anywhere from 5% to 25% of the patients who were hospitalized, which Hurst said is enough to indicate there is something “concerning” about the new coronavirus and the heart.
“Even after the infection is resolved, there are anecdotal reports of people that are still battling fatigue and other symptoms, and whether that warrants a heart evaluation, I don’t know the answer,” Hurst said.
“But if I saw a patient like that, that had those ongoing symptoms — they were short of breath, they were fatigued, they didn’t have the energy — I certainly think a cardiac screening evaluation for them would at least make sense.”
Christopher Ruggles, a 49-year-old dog walker who lives in Arizona, said he’s been living with COVID-19 symptoms since mid-March. He wasn’t able to get a test during the early weeks of his illness and has since tested negative three times. An antibody test came up negative, too.
But Ruggles can’t think of any other cause for his lingering fatigue, cough and muscle weakness that has left him unable to work. While he normally was walking 10 to 12 miles a day, he can now barely do 30 minutes of yoga, he said.
Ruggles just connected with a third doctor. The first two did not take his symptoms seriously, but he persisted. He’s part of a COVID “long-haulers” group for people with residual problems from the virus and he is hoping to get a cardiac MRI. An EKG did not show any heart damage, but Ruggles remains concerned.
“I worry about my heart,” he said.
Heart symptoms include ‘decreased exercise tolerance’
Any COVID-19 survivor who has lingering symptoms like heart palpitations that could indicate heart trouble should follow up with a cardiologist, said Dr. Pallavi Bellamkonda, a cardiologist with the Heart and Vascular Institute at Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix.
Similarly, Pedrotty said she has a patient who had COVID-19 and recovered at home but is now experiencing chest tightness. A stress test was negative and Pedrotty is now looking for “residual inflammation.”
“For those patients, we do recommend a cardiac MRI,” she said. “Obviously the [medical] societies have not all put out guidelines. It’s a bit premature, but I think a lot of us suspect that if we do have COVID patients that have subsequently recovered and now have symptoms, an MRI is appropriate.
Bellamkonda said other symptoms COVID-19 survivors should watch for that could signal heart trouble include persistent chest pains, shortness of breath and once they are fully recovered a “decrease in exercise tolerance” — not being able to do something like run a mile that a person could easily do prior to getting sick, for example.
Pedrotty said COVID-19 is not just a cardiac disease: It’s cardiovascular, too, which means it could involve the body’s blood vessels.
“There have been a lot of studies published about patients having clots and pulmonary embolisms and all of these types of things that have happened, especially in the severely ill,” she said.
“We’re just starting trials to understand the hematologic aspects of this. We know there’s some endothelial damage, and that’s what lines all your blood vessels.”
Not everyone who has had COVID-19 needs a cardiac screening, but the illness can cause extreme reactions in the body, she added.
