In October 2020, Kim and colleagues, representing the American College of Cardiology’s Sports and Exercise Council, published recommendations¹ for the evaluation of athletes who had tested positive for COVID-19 to ensure safe return to play. The group recommended a tiered approach based on the presence of symptoms, followed by electrocardiography (ECG), injury biomarkers, and echocardiography. Abnormalities were then to be further characterized by the selective use of cardiac magnetic resonance (CMR) imaging. The recommendations were based on expert opinion of experienced sports cardiologists, because there were at the time only modest data to inform such a document. A report² on 26 college athletes who were asymptomatic or had only mild symptoms found CMR evidence of myocarditis in 4 (15%). Both the Kim et al report¹ and our Editorial³ at the time called for larger data sets, so that recommendations could be refined and more informed by data.

In only 6 months since then, there has been a remarkable amount of information acquired, analyzed, and published regarding post–COVID-19 prevalence of cardiac abnormalities in athletes, as summarized in the Table.^2,4-11 In a recent study of 789 professional athletes, screening consisted of serum troponin testing, ECG, and echocardiography, regardless of symptoms.⁸ Thirty of these athletes (3.8%) had abnormal test results resulting in referral for CMR imaging, with 3 diagnosed with myocarditis. Similarly, in a large cohort of 3018 college athletes from 42 universities,⁹ a strategy using serum troponin tests, ECG, and echocardiography identified 15 athletes (0.5%) with possible cardiac involvement. In a subgroup of 198 athletes in that report⁹ who underwent a primary CMR imaging–based screening strategy (ie, without selection by the other tests), a higher proportion of athletes demonstrated definite, probable, or possible cardiac involvement (n = 6 [3.0%]).

In the current issue of JAMA Cardiology, a study by Daniels et al¹¹ adds substantially to the extant information. As they note, starting in September 2020, the Big Ten athletic conference (involving 13 major universities) mandated comprehensive cardiac screening, including ECG, troponin testing, echocardiography, and CMR imaging for athletes in the aftermath of positive COVID-19 test results, regardless of prior symptomatic status. The authors report on a large sample of 2461 athletes, of whom 1597 (64.9%) had the complete comprehensive screening testing, including CMR imaging without prior selection. They found that 37 (2.3%) of these athletes demonstrated diagnostic criteria for myocarditis by CMR imaging, including 20 without cardiovascular symptoms and with normal ECG, echocardiography, and troponin test results, who would not have been identified without CMR imaging. While some of the prior studies involving smaller patient cohorts had also reported all athletes undergoing CMR imaging,^2,4,5 it was unclear what selection may have taken place before CMR imaging referral.

2020 年 10 月，代表美国心脏病学会运动与锻炼委员会的 Kim 及其同事发布了建议^1，用于评估 COVID-19 检测呈阳性的运动员，以确保安全返回比赛。该小组推荐了一种基于症状存在的分层方法，然后是心电图 (ECG)、损伤生物标志物和超声心动图。然后通过选择性使用心脏磁共振 (CMR) 成像来进一步表征异常。这些建议是基于经验丰富的运动心脏病专家的专家意见，因为当时只有少量数据可以为此类文件提供信息。一份报告²在 26 名无症状或仅有轻微症状的大学运动员中，有 4 名 (15%) 发现心肌炎的 CMR 证据。Kim 等人的报告¹和我们当时的社论³都要求使用更大的数据集，以便可以根据数据改进建议并提供更多信息。

从那时起仅 6 个月，就获得、分析和发表了大量关于 COVID-19 后运动员心脏异常患病率的信息，如表所示。^{2 ,4 -11}在最近对 789 名职业运动员的研究中，筛查包括血清肌钙蛋白检测、心电图和超声心动图，无论症状如何。⁸这些运动员中有 30 人 (3.8%) 的检测结果异常，导致转诊进行 CMR 成像，其中 3 人被诊断为心肌炎。同样，在来自 42 所大学的 3018 名大学生运动员组成的大型队列中，⁹一项使用血清肌钙蛋白测试、心电图和超声心动图的策略确定了 15 名运动员 (0.5%) 可能有心脏受累。在该报告中的 198 名运动员亚组中⁹接受了基于 CMR 成像的初级筛查策略（即，没有通过其他测试进行选择），更高比例的运动员证明明确、可能或可能的心脏受累（n = 6 [9]）。 3.0%]）。

在最新一期的JAMA Cardiology 中，Daniels 等人的一项研究¹¹大大增加了现存的信息。正如他们所指出的，从 2020 年 9 月开始，十大运动会议（涉及 13 所主要大学）要求在 COVID-19 检测结果呈阳性后对运动员进行全面的心脏筛查，包括心电图、肌钙蛋白检测、超声心动图和 CMR 成像，无论先前的症状状态。作者报告了 2461 名运动员的大样本，其中 1597 名 (64.9%) 进行了完整的综合筛查测试，包括未经事先选择的 CMR 成像。他们发现，这些运动员中有 37 名（2.3%）通过 CMR 成像证明了心肌炎的诊断标准，其中 20 名没有心血管症状且心电图、超声心动图和肌钙蛋白测试结果正常，如果没有 CMR 成像，他们将无法被识别。^{2 ,4 ,5}不清楚在 CMR 成像转诊之前可能进行了哪些选择。