Italian return to play protocol after COVID-19 in young competitive and professional athletes: diagnostic yield and cost-benefit analysis

BACKGROUND: Return to play (RTP) protocols have been proposed to early detect cardiovascular involvement due to COVID-19 and reduce the risk of sports-related sudden cardiac death. However, uncertainties remain about the true prevalence of COVID-19 myopericarditis, the arrhythmic risk and the cost of this protocol. METHODS: We collected data from 217 competitive and professional athletes of both genders who underwent RTP protocol (clinical history, resting and exercise ECG, and echocardiography). Holter monitoring and/or cardiac magnetic resonance (CMR) were performed in case of abnormalities. In 107 athletes, the RTP data were compared with those of preparticipation evaluation (PPE) performed prior to COVID-19 infection. RESULTS: Out of 217 consecutive athletes evaluated with the RTP protocol, 7 underwent CMR: among these we found alterations compatible with myopericarditis in 3 (1.4%), with a cost per person of € 223.93 and a cost per diagnosis of € 16,197.53. Of the 107 athletes previously evaluated with PPE, 4 underwent RMC: we made a final diagnosis of myocarditis in 1 athlete (0.9%), whereas another athlete (0.9%) showed moderate pericardial effusion. The clinical presentation of both these athletes was characterized by the presence of ventricular arrhythmias newly detected during RTP. Compared to PPE, during RTP higher values were observed for shortness of breath, weight, heart rate and corrected QT interval, whereas lower values for sinus bradycardia and the E/A ratio of mitral flow. CONCLUSIONS: The prevalence of myopericarditis was similar to that reported in previous cross-sectional and case-control studies. The availability of data recorded before COVID-19 was important in the evaluation of athletes with arrhythmias. The RTP protocol has proven to be less cost effective than normal PPE.