Take Effects of COVID-19 to Heart

August 19, 2020 – When Ken Koontz tested positive for coronavirus in mid-July, he had every reason to believe he would make a full recovery and be fine. The 53-year-old from Woodstock, GA, is a 16-time Ironman and Half-Ironman finisher, professional triathlon coach and longtime swimmer.

The sickest of the sick, he had heard, appeared to be older people with other health problems, such as diabetes, high blood pressure and obesity. But then it became known this month that Boston Red Sox pitcher Eduardo Rodriguez will be out for the rest of the season due to a heart problem caused by COVID-19.

Doctors know relatively little about all of the possible side effects of COVID-19 and the potential for long-term problems. After all, it’s still a new virus. But growing evidence suggests that anyone who catches the virus – from the sick and the elderly to elite athletes – is at risk for heart damage.

“With any viral infection, there is the potential to affect the heart, but COVID-19 seems to affect the heart more than other viruses,” says Eugene Chung, MD, director of sports cardiology at the University of Michigan Frankel Cardiovascular Center.

Survival of the fittest

A few days after Koontz felt better and allowed to return to work, he started training again. He resumed exercising with moderate strength training for a few weeks. Then he felt ready to go back to the pool.

During a workout that should have been relatively easy for him, he said, “My heart was racing. After a few intervals, I was out of breath. While swimming he was experiencing a particular kind of muscle pain that he knew from a career in fitness meant his muscles were not getting enough oxygen.

“Workout after workout, I hadn’t progressed as quickly – in terms of cardiovascular endurance – as I would have hoped. I still have trouble swimming 500 meters.

Heartbeat and shortness of breath, even during exercise, can be signs of myocarditis, a life-threatening inflammation of the heart usually caused by a virus. Other symptoms include chest pain, especially when lying down; swelling of the legs, ankles or feet; and fatigue. Myocarditis may go away on its own with rest. But, exercising at elite athlete level before the heart has had time to recover can make it worse, even fatal.

“For athletes, myocarditis is a common cause of sudden cardiac arrest or sudden cardiac death,” Jonathan Kim, MD, head of sports cardiology at Emory Healthcare in Atlanta, said at a press conference.

Once an athlete has confirmed myocarditis, doctors usually recommend a full 3 months of rest before resuming intense training. That’s why the Boston Red Sox had to put their pitcher on the sidelines for the rest of the season.

The American College of Cardiology Sports and Exercise Council recently proposed guidelines for athletes who have had COVID-19. The group recommends that they have an electrocardiogram (or ECG, a test that detects electrical activity of the heart and may show arrhythmia or signs of heart damage), an echocardiogram (an ultrasound of the heart, which can examine heart function or structural damage) and blood tests to make sure the heart is working properly before resuming practice.

“If all of this is normal,” Kim said, “it would be reasonable to allow the athlete to resume training.”

Everyone is at risk

But it may not take Olympic-level training to damage the heart after COVID-19.

Preliminary data suggests that up to 1 in 5 people who go to hospital for the virus end up with some kind of heart injury. “This lesion is defined in several ways: worsened cardiac function, arrhythmias or release of cardiac troponin. [a sign of heart injury that a blood test can detect]Kim said.

And new research suggests that people who do not go to the hospital can also suffer from heart damage. In one study, researchers followed 100 people, aged 49 to 53, who had had COVID-19. Just over 30 of them had to go to hospital for their illness, and nearly 70 had recovered at home. This is important because physicians tend to view those who recover at home without medical attention as “mild to moderate” cases. But more than a month after being diagnosed with COVID-19, nearly 80 people showed signs of heart damage, including changes visible on an MRI; abnormal blood tests; and inflammation of the heart.

In the grand scheme of things, a study of 100 people isn’t much evidence, but according to the doctors who analyzed the study, 80% is still too much to ignore. Ultimately, doctors don’t yet have enough information to describe exactly who is at risk of heart damage, how high that risk can be, and how far the effects can reach. But the signs point to some level of risk for anyone catching the virus.

“We always learn as we go,” says Chung. “Hopefully over the next few months we have enough experience and enough reporting on people who may be at higher risk.”

As for mere mortals who want to return to moderate exercise, not an Ironman competition, after recovering from COVID-19, Kim offers this advice.

“For your average exerciser, someone who has committed to guideline recommended doses of exercise, is slowly increasing. Don’t start exercising again like you have a cold. Go up slowly, and if there are any disturbing symptoms, go back down and contact a healthcare practitioner. “

Despite being aware of the heart risk, Koontz changed his workouts rather than cutting them out entirely. Today he says his workouts are getting easier and he’s starting to feel more like his old self.

But COVID-19 has taught him a hard lesson.

“I always thought I could fix everything with diet and exercise,” he says. “Now I hear people say, ‘I’m in good shape, I’m in good health, I’m young, that’s not going to happen to me.’ It can happen to anyone. And the long-term effects worry me a lot more than death.


Ken Koontz, COVID-19 survivor, Woodstock, Georgia.

Eugene Chung, MD, director, athletic cardiology, University of Michigan Medicine Frankel Cardiovascular Center, Ann Arbor.

Jonathan Kim, MD, chief, sports cardiology, Emory University, Atlanta.

Mayo Clinic: “Myocarditis”.

JAMA Cardiology: “Cardiovascular Magnetic Resonance Imaging Results in Recently Recovered Patients from 2019 Coronavirus Disease (COVID-19).”

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