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Myocarditis Risk With COVID-19

BY Dr. Jeff Sankoff

For patients who have recovered from COVID-19, myocarditis may cause lingering complications, even among seemingly-healthy athletes.

COVID-19 will forever be the defining element of 2020. For the vast majority of us, this will mean reflecting on lockdowns, social distancing, masks, and the social dynamics involved when politics and pandemics get mixed up. For others, 2020 will be remembered as the year that loved ones were lost to the virus, while others still will reflect on how they got the illness but survived. For those who recover from COVID-19, most will be symptom-free after a few weeks—but some will continue to deal with the effects for months.

Among the group who have seemingly recovered, there is a group that may have a silent complication—one which can cause death long after the initial illness has receded. Myocarditis, or inflammation of the heart, has been reported in patients with COVID-19, and while the magnitude of this problem remains unclear, it can cause serious risks to young, otherwise healthy athletes.

In many cases myocarditis doesn’t cause much in the way of symptoms, but as the heart heals there can be changes to its architecture. These changes can be fatal—principally by making the heart prone to certain types of arrhythmia, which can come on when the person is exercising. Myocarditis is thought to account for 8% of sudden cardiac deaths in athletes, dwarfing the number of deaths attributed to swimming-induced pulmonary edema, a cause that gets a lot more attention and concern.

In the eight months since COVID-19 has become a significant issue in Europe and North America, cardiologists have tried to get a handle on the magnitude of this problem as well as formulate guidelines for how to advise patients on when they are safe to return to exercise and what (if any) screening they should undergo beforehand.

It isn’t too surprising that there is a LOT of hand waving going on in this regard, as there is so little known and so much to speculate upon. As a result, given the enormous potential downsides, guidelines for return to exercise have tended to be both very conservative and very inconsistent.

One group of cardiologists from Boston, for example, would have every single patient who recovers from COVID-19 undergo some kind of screening, with the vast majority getting an echocardiogram. Given that over a million Americans have had this disease, you can imagine this may not be tenable.

A different guideline from cardiologists in the Netherlands separated patients first into those who had been symptomatic with COVID-19 and those who had not had any symptoms at all.

For asymptomatic patients, this guideline recommends no exercise whatsoever for at least ten days from the time of diagnosis, and then a gradual return to exercise without any screening. If any symptoms develop (such as shortness of breath or chest pain) additional screening is recommended.

Patients who had an infection with symptoms are subdivided into those who were hospitalized and those who were not. For patients who did not require hospitalization, no exercise at all should be done while symptoms persist, nor for 10 days afterwards. Then a pre-screening is recommended for all, with an electrocardiogram and evaluation by a primary care physician. Based on that assessment, additional tests may be needed, but in most cases that patient will be cleared and a gradual return to exercise can begin.

Patients who were hospitalized would require a more extensive screening, including an echocardiogram. In some cases they may be restricted from exercising for up to six months. There is a lot of variability within this group depending on how severe their illness was and whether or not there were biochemical signs of heart involvement during hospitalization.

All of this is to say, COVID-19 infection is no joke. It is a nasty disease and everyone should do whatever they can to avoid getting it. If you have already had it, and especially if you have lingering symptoms, you may want to consult your doctor before resuming exercise. The guidelines above are sobering, and should be regarded with the seriousness in which they were developed.

Do you have a question about this or anything else related to health, wellbeing and triathlon training and racing? Send me an email at

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About Dr. Jeff Sankoff

Jeff Sankoff is an Emergency Physician, long time triathlete and USAT/IRONMAN University Certified coach. He has completed 6 IRONMAN races (including Kona) and more than fifty races at the 70.3 distance including 5 World Championships. He produces the TriDoc Podcast that can be found on most popular podcast platforms and iWork’s with LifeSport Coaching. You can learn more about him at his website: TriDoc Coaching.

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