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Specific Cardiovascular Diseases and Competitive Sports Participation: Myocarditis and Myocardial Fibrosis

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Textbook of Sports and Exercise Cardiology

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Abstract

According to recent epidemiologic studies, myocarditis represents one of the major causes of sudden cardiac death among young competitive athletes. Myocarditis can be caused by infectious agents (with viral myocarditis being the leading cause), systemic auto-immune diseases, medical drugs and toxic agents. Since myocarditis is an acquired disease, systematic screening programs will fail to depict this disease. Nevertheless, an adapted prevention can decrease its incidence in athletes. Information on not to train in case of infection and systemic symptoms and on the potential adverse effects of doping agents and recreational drugs is essential for the prevention of myocarditis in athletes. The diagnosis of myocarditis is challenging, due to the heterogeneity of its clinical presentation. Cardiovascular symptoms, ECG and echocardiographic changes, as well as elevation of troponin are rather unspecific. If these first line examinations are suggestive, cardiac MRI should be performed, and the diagnosis should be based on the Lake Louise Consensus criteria. Endomyocardial biopsy, the gold standard for diagnosis, should be limited to recent-onset, high-risk major clinical syndromes not responding to conventional medical therapy. In case of myocarditis, the treatment is essentially symptomatic and based on the management of arrhythmic and heart failure complications. Sport restriction is of course warranted in order to prevent potential lethal arrhythmias and to decrease the risk of negative ventricular remodelling. Athletes with a diagnosis of myocarditis should be restricted from exercise programs for a period of 3–6 months. Asymptomatic patients might be able to resume training and competition if serum markers of myocardial injury, inflammation, and heart failure have normalized, if ventricular systolic function has returned to the normal range, and if no significant arrhythmia occurs on a 24-h ECG monitoring and during an exercise test.

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Authors and Affiliations

  1. Department of Sports Medicine, University Hospital of Rennes, Rennes1 University, Inserm, Rennes, France

    Frédéric Schnell & François Carré

Authors
  1. Frédéric Schnell
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  2. François Carré
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Corresponding author

Correspondence to François Carré .

Editor information

Editors and Affiliations

  1. Private Center for Sports and Exercise Cardiology, München, Bayern, Germany

    Axel Pressler

  2. University Institute of Sports Medicine Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria

    Josef Niebauer

Review

Review

1.1 Questions

  1. 1.

    Regarding different diagnostic tools of myocarditis in athletes, which of the following statements is correct?

    1. (a)

      A slight increase of troponin after intense exercise is always pathological.

    2. (b)

      Pathological ECG changes are always present in myocarditis.

    3. (c)

      Regional wall motion abnormalities on imaging techniques are always present in myocarditis.

    4. (d)

      Late gadolinium enhancement is always present in myocarditis.

    5. (e)

      None of the answers is correct.

  2. 2.

    Which of the following statements are correct? Clearance of athletes regarding competitive sports practice after a myocarditis is possible:

    1. (a)

      If the athlete is asymptomatic.

    2. (b)

      If serum markers of myocardial injury, inflammation, and heart failure have normalized.

    3. (c)

      If LV systolic function has returned to the normal range.

    4. (d)

      If no significant arrhythmia occurs on a 24-h ECG monitoring and exercise test.

    5. (e)

      If there is no more LGE on control CMR.

1.2 Answers

  1. 1.

    (e)

    The diagnosis of myocarditis is difficult. Indeed, except endomyocardial biopsy, none of the diagnostic tools that are at our disposal are specific nor sensitive.

    • Troponin can increase slightly after endurance exercise. Therefore, it is necessary to take previous physical exercise into account when a cardiac emergency is suspected.

    • ECG abnormalities are only present in less than 50% of patients with suspected myocarditis.

    • Regional wall motion abnormalities can be present, and LV global systolic function can range from normal to severely altered, but this is also not always the case.

    • A certain number of patients with biopsy proven myocarditis do not show LGE.

  2. 2.

    (a–d)

    The clinical significance of persistent LGE in an asymptomatic athlete with clinically healed myocarditis is unknown, however, myocardial scar is a potential source of ventricular tachyarrhythmias. At present, it seems reasonable for these athletes to resume training and participate in competitive sport if LV function is preserved and in the absence of frequent or complex repetitive forms of ventricular or supraventricular arrhythmias during maximal exercise and on 24-h ECG monitoring (including a session of training or competition). Asymptomatic athletes with LGE, however, should remain under annual clinical surveillance.

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Schnell, F., Carré, F. (2020). Specific Cardiovascular Diseases and Competitive Sports Participation: Myocarditis and Myocardial Fibrosis. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_19

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