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Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players
  1. Raghav T Bhatia1,
  2. Aneil Malhotra1,2,
  3. Hamish MacLachlan1,
  4. Sabiha Gati1,3,
  5. Sarandeep Marwaha1,
  6. Nikhil Chatrath1,
  7. Saad Fyyaz1,
  8. Haroldo Aleixo4,
  9. Samar Al-Turaihi1,
  10. Aswin Babu1,
  11. Joyee Basu1,
  12. Paul Catterson5,
  13. Robert Cooper6,
  14. Joelle J N Daems7,
  15. Harshil Dhutia1,
  16. Filipe Ferrari8,
  17. Juliette C van Hattum7,
  18. Zafar Iqbal9,
  19. Alexandros Kasiakogias1,
  20. Antoinette Kenny10,
  21. Tamim Khanbhai11,
  22. Shafik Khoury1,
  23. Chris Miles1,
  24. David Oxborough12,
  25. Kashif Quazi1,
  26. Dhrubo Rakhit13,
  27. Anushka Sharma1,
  28. Amanda Varnava14,
  29. Maria Teresa Tome Esteban1,
  30. Gherardo Finocchiaro1,
  31. Ricardo Stein8,
  32. Harald T Jorstad7,15,
  33. Michael Papadakis1,
  34. Sanjay Sharma1
  1. 1 Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
  2. 2 Manchester Academic Health Science Centre, Manchester University National Health Service Foundation Trust, Manchester, UK
  3. 3 Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
  4. 4 Hospital Mater Dei, Belo Horizonte, Brazil
  5. 5 Department of Medicine, Newcastle United Football Club, Newcastle, UK
  6. 6 Liverpool Heart and Chest Hospital, Liverpool, UK
  7. 7 Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
  8. 8 Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Rio, Brazil
  9. 9 Department of Sports Medicine, Crystal Palace Football Club, London, UK
  10. 10 Cardiothoracic Centre, Freeman Hospital, Newcastle, UK
  11. 11 Tottenham Hotspur Football Club, London, UK
  12. 12 Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
  13. 13 Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  14. 14 Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
  15. 15 Amsterdam Cardiovascular Sciences, Amsterdam Movement Sciences, Amsterdam, The Netherlands
  1. Correspondence to Professor Sanjay Sharma, Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK; sasharma{at}sgul.ac.uk

Abstract

Background and aim The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection.

Methods In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes.

Results 511 soccer players (median age 21 years, IQR 18–26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3–10) compared with athletes without de-novo ECG changes (2 days, IQR 1–3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%.

Conclusions 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

  • Electrocardiography
  • Cardiomyopathies
  • Myocarditis

Data availability statement

Data are available upon reasonable request. Requests should be made to the senior author SS.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/heartjnl-2022-322211

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    Data availability statement

    Data are available upon reasonable request. Requests should be made to the senior author SS.

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    Footnotes

    • MP and SS are joint senior authors.

    • Twitter @DrRaghavBhatia, @DrAneilMalhotra, @s_gati, @DrSaranMarwaha, @chatrath_nikhil, @sfyyaz, @HaroldoCAleixo, @aswinbabu1412, @BasuJoyee, @robcoops82, @harshil_dhutia, @sportsdrzaf, @AKasiakogias, @tamim_sportsdoc, @DrShafikKhoury, @DrCJMiles, @oxborough77, @KashQuazi, @Nushh_x, @AmandaVarnava, @DrMaiteTome, @gherardobis, @MichaelPapadak2, @SSharmacardio

    • Contributors All authors were involved in conception, design, analysis and interpretation of data, and drafting the article. All authors critically revised the manuscript and approved the final version to be published. MP and SS contributed jointly as senior authors and are both guarantors for the work.

    • Funding RTB, HM, SM, NC and SF are funded by research grants from the charitable organisation Cardiac Risk in the Young, which promotes cardiac screening in young individuals. RS is an established investigator of the Conselho Nacional de Pesquisa, Brazilia, Brazil.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein) or of any geographical or locational reference does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area, or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests SS is on the editorial board of Heart BMJ.

    • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.