Cardiovascular Risk Assessment after COVID-19 Infection before Resuming Sports Activities - Practical Flowchart and Meta-Analysis

Puga, Luís; Dinis, Paulo; Teixeira, Rogério; Ribeiro, Joana Maria; Dores, Hélder; Gonçalves, Lino

doi:10.36660/ijcs.20200288

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International Journal of Cardiovascular Sciences

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Original Article • Int. J. Cardiovasc. Sci. 35 (1) • Jan-Feb 2022 • https://doi.org/10.36660/ijcs.20200288 copy

Cardiovascular Risk Assessment after COVID-19 Infection before Resuming Sports Activities - Practical Flowchart and Meta-Analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

The risk of sports-related sudden cardiac arrest after COVID-19 infection can be a serious problem. There is an urgent need for evidence-based criteria to ensure patient safety before resuming exercise.

Objective:

To estimate the pooled prevalence of acute myocardial injury caused by COVID-19 and to provide an easy-to-use cardiovascular risk assessment toolkit prior to resuming sports activities after COVID-19 infection.

Methods:

We searched the Medline and Cochrane databases for articles on the prevalence of acute myocardial injury associated with COVID-19 infection. The pooled prevalence of acute myocardial injury was calculated for hospitalized patients treated in different settings (non-intensive care unit [ICU], ICU, overall hospitalization, and non-survivors). Statistical significance was accepted for p values <0.05. We propose a practical flowchart to assess the cardiovascular risk of individuals who recovered from COVID-19 before resuming sports activities.

Results:

A total of 20 studies (6,573 patients) were included. The overall pooled prevalence of acute myocardial injury in hospitalized patients was 21.7% (95% CI 17.3-26.5%). The non-ICU setting had the lowest prevalence (9.5%, 95% CI 1.5-23.4%), followed by the ICU setting (44.9%, 95% CI 27.7-62.8%), and the cohort of non-survivors (57.7% with 95% CI 38.5-75.7%). We provide an approach to assess cardiovascular risk based on the prevalence of acute myocardial injury in each setting.

Conclusions:

Acute myocardial injury is frequent and associated with more severe disease and hospital admissions. Cardiac involvement could be a potential trigger for exercise-induced clinical complications after COVID-19 infection. We created a toolkit to assist with clinical decision-making prior to resuming sports activities after COVID-19 infection.

Keywords:
Risk Factors; COVID-19; Betacoronavirus; Myocarditis; Inflammation; Sudden Cardiac Death; Sports Medicine; Sports

						Number of participants included (n)
Author	Cohort (setting)	Location	Age	Males	Previous CVD	Non-ICU	ICU	Non-Survivors	Overall Hospitalized
Huang, C¹⁷17. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.	Hospitalized (ICU vs Non-ICU)	Wuhan, China Jinyintan Hospital	49 (41–58)	73	15	28	13		41
Zhou, F¹⁸18. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, 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(10229):1054-62.	Hospitalized (Survivors vs Non-survivors)	Wuhan, China Jinyintan Hospital and Pulmonary Hospital	56 (46–67)	62	30 HTN 19 DM 8 CAD			54	191
Wang, D⁷7. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-9.	Hospitalized (ICU vs Non-ICU)	Wuhan, China Zhongnan Hospital	56 (42-68)	75	20	102	36		138
Shi, S¹⁹19. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020;5(7):802-10.	Hospitalized (Cardiac injury vs without cardiac injury)	Wuhan, China Renmin Hospital	64 (range 21-95)	49.3	30.5 HTN 14.4 DM 10.6 CAD				416
Guo, T ⁸8. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):811-8.	Hospitalized (Cardiac injury vs without cardiac injury)	Wuhan, China Seventh Hospital	58.5 (14.7)	48.7	32.6 HTN 15.0 DM 11.2 CAD				187
Yang, X²⁰20. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475-81.	ICU (survivors vs non-survivors)	Wuhan, China Jinyintan Hospital	59.7 (13.3)	67	10		52	32
Ruan, Q²¹21. Ruan Q, Yang K, Wang W, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;46(5):846-8.	Hospitalized (survivors vs non-survivors)	Wuhan, China Jinyintan Hospital	50 (44-81) 67 (15-81)	68	8.7			68
Zhou, B²²22. Zhou B, She J, Wang Y, Jiang L, Song J. The clinical characteristics of myocardial injury in severe and very severe patients with 2019 novel coronavirus disease. J Infect. 2020;81(1):147-8.	Hospitalized (Severe vs Very Severe)	Wuhan, China Tongji Medical College	63 (58-69) 67 (66-75)	50	0^† † Excluded patients with previous cardiovascular disease	26 SEVERE^* * Severe disease considered as one of the following: 1) Respiratory distress with respiratory rate more than 30 times/min; 2) Oxygen saturation ≤93% in resting state; 3) PaO2/FiO2≤300mmHg; Very severe disease considered as one of the following: 1) Respiratory failure in need of mechanical ventilation; 2) Shock; 3) Other organ dysfunction.	8 VERY SEVERE^* * Severe disease considered as one of the following: 1) Respiratory distress with respiratory rate more than 30 times/min; 2) Oxygen saturation ≤93% in resting state; 3) PaO2/FiO2≤300mmHg; Very severe disease considered as one of the following: 1) Respiratory failure in need of mechanical ventilation; 2) Shock; 3) Other organ dysfunction.
Yang, F²³23. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol. 2020;92(11):2511-5.	Non-survivors	Wuhan, China Renmin Hospital	69.8 (15)	53.3	17.4			92
Deng, Q²⁴24. Deng Q, Hu B, Zhang Y, Wang H, Zhou X, Hu W, et al. Suspected myocardial injury in patients with COVID-19: evidence from front-line clinical observation in Wuhan, China. Int J Cardiol. 2020 Jul 13;311:116-21.	Hospitalized (Severe vs Very Severe)	Wuhan, China Renmin Hospital	65 (49-71)	50.9	32.1 HTN 17.0 DM 13.4 CAD	45 NON-SEVERE^‡ ‡ Severe defined as having one of the following: respiratory distress and respiratory rate higher than 30 times per minute; fingertip blood oxygen saturation less than 93% at rest; partial arterial oxygen pressure (PaO2) / fraction of inspiration oxygen (FiO2) less than 300mmHg, respiratory failure requiring mechanical ventilation; shock; multiple organ failure, requiring intensive care management	67 SEVERE^‡ ‡ Severe defined as having one of the following: respiratory distress and respiratory rate higher than 30 times per minute; fingertip blood oxygen saturation less than 93% at rest; partial arterial oxygen pressure (PaO2) / fraction of inspiration oxygen (FiO2) less than 300mmHg, respiratory failure requiring mechanical ventilation; shock; multiple organ failure, requiring intensive care management		112
Aggarwal, S²⁵25. Aggarwal S, Garcia-Telles N, Aggarwal G, Lavie C, Lippi G, Henry BM. Clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19): early report from the United States. Diagnosis (Berl). 2020;7(2):91-6.	Hospitalized (Severe vs non-severe)	Iowa, USA UnityPoint, Des Moines Hospital	67 (range 38-95)	75	57 HTN 19 DM 19 CAD				16
Wei, J²⁶26. Wei JF, Huang FY, Xiong TY, Liu Q, Chen H, Wang H, et al. Acute myocardial injury is common in patients with covid-19 and impairs their prognosis. Heart. 2020;106(15):1154-9.	Hospitalized (Cardiac injury vs without cardiac injury)	Sichuan, China Chengdu and West China Hospital	49 (34-62)	54	21 HTN 14 DM 5 CAD				101
Li, D²⁷27. Li D, Chen Y, Jia Y, Tong L, Wang W, Liu Y, et al. SARS-CoV-2-induced immune dysregulation and myocardial injury risk in China: insights from the ERS-COVID-19 study. Circ Res. 2020;127(3):397-9.	Hospitalized (Cardiac injury vs without cardiac injury)	China ERS-COVID-19 study (2 hospitals)²⁸28. Chinese Clinical Trial Register [Internet]. West China Hospital, Sichuan University. 2020 Mar 05 - . Identifier ChiCTR2000030494, Early risk stratification of the novel coronavirus infected diseases (COVID-19): a multicenter retrospective study (ERS-COVID-19 study). [citado 30 jan 2020]. Disponível em: http://www.chictr.org.cn. http://www.chictr.org.cn...	CI 71 (66-83), No CI 60 (48-68)	CI 24 (61.5), No CI 75 (52.4)	0^† † Excluded patients with previous cardiovascular disease				182
Shi, S²⁹29. Shi S, Qin M, Cai Y, Liu T, Shen B, Yang F, et al. Characteristics and clinical significance of myocardial injury in patients with severe coronavirus disease 2019. Eur Heart J. 2020;41(22):2070-9.	Severe and critical hospitalized patients (survivors vs non-survivors)	Wuhan, China Renmin Hospital	63 (50– 72)	48	29.7 HTN 14.5 DM 8.9 CAD		671	62
Ni, W³⁰30. Ni W, Yang X, Liu J, Bao J, Li R, Xu Y, et al. Acute myocardial injury at hospital admission is associated with all-cause mortality in COVID-19. J Am Coll Cardiol. 2020;76(1):124-5.	Hospitalized (survivors vs non-survivors)	Wuhan, China Central Hospital	67 (57–73)	57.4	49.3 HTN 26.7 DM 14.2 CAD			60	176
Yang, Q³¹31. Yang Q, Xie L, Zhang W, Zhao L, Wu H, Jiang JJ, et al. Analysis of the clinical characteristics, drug treatments and prognoses of 136 patients with coronavirus disease 2019. J Clin Pharm Ther. 2020;45(4):609-16.	Hospitalized (moderate vs severe or critical)	Wuhan, China Third Hospital	56 (44-64)	48.5	27.1 HTN 14.7 DM	103 MODERATE^§ § Moderate considered as having one of the following: fever and respiratory symptoms, pneumonia manifestations in the imaging; Severe and critical defined as having one of the following: shortness of breath with respiratory rate (RR) ≥30 bpm or finger SpO2 ≤93% at rest, respiratory failure (requiring mechanical ventilation), shock or other organ failure (requiring ICU monitoring and treatment)	33 SEVERE/CRITICAL^§ § Moderate considered as having one of the following: fever and respiratory symptoms, pneumonia manifestations in the imaging; Severe and critical defined as having one of the following: shortness of breath with respiratory rate (RR) ≥30 bpm or finger SpO2 ≤93% at rest, respiratory failure (requiring mechanical ventilation), shock or other organ failure (requiring ICU monitoring and treatment)		136
Zhao, M³²32. Zhao M, Wang M, Zhang J, Gu J, Zhang P, Xu Y, et al. Comparison of clinical characteristics and outcomes of patients with coronavirus disease 2019 at different ages. Aging (Albany NY). 2020;12(11):10070-86.	Hospitalized	Wuhan, China Renmin Hospital	61 (46-70)	46.6	28.2 HTN 11.8 DM 6 CAD				1000
Arentz, M³³33. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 critically Ill patients With COVID-19 in Washington State. JAMA. 2020;323(16):1612-4.	Hospitalized in ICU	Washington state, USA Evergreen Hospital	70 (range, 43-92)	52	33.3 DM		21
Richardson, S³⁴34. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052-9.	Hospitalized	12 hospitals in New York, USA	63 (52-75)	60.3	56.6 HTN 33.8 DM 11.1 CAD				3522
Suleyman, G¹⁶16. Suleyman G, Fadel RA, Malette KM, Hammond C, Abdulla H, Entz A, et al. Clinical characteristics and morbidity associated with coronavirus disease 2019 in a series of patients in Metropolitan Detroit. JAMA Netw Open. 2020;3(6):e2012270.	Admitted to Emergency department	Hospitals in Henry Ford Health System in Detroit, Michigan, USA	57.5 (16.8)	44.1	63.7 HTN 38.4 DM 12.7 CAD	214	141		355
Total number of participants						518	1042	368	6573

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[1] Mailing Address: Luís Puga, Centro Hospitalar e Universitário de Coimbra EPE - Cardiologia Rua 5 de Outubro, S. Martinho do Bispo, s/n. Postal Code: 3049-002, Coimbra –Portugal. E-mail: luis.romeu.puga@gmail.com