Aug. 19, 2020 — When Ken Koontz tested positive for the coronavirus in mid-July, he had every reason to believe he’d recover fully and be just fine. The 53-year-old from Woodstock, GA, is a 16-time Ironman and Half-Ironman finisher, a professional triathlon coach, and a lifelong swimmer.
The sickest of the sick, he had been hearing, seemed to be older folks with other health problems, like diabetes, high blood pressure, and obesity. But then, word came this month that Boston Red Sox pitcher Eduardo Rodriguez would sit out the rest of the season due to a heart problem caused by COVID-19.
Doctors know relatively little about all the possible side effects of COVID-19 and the potential for long-term problems. After all, it’s still a new virus. But a growing body of evidence suggests that anyone who gets the virus — from the sick and the elderly to elite athletes — faces the risk of heart damage.
“With any viral infection, there’s 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 was feeling better and cleared to go back to work, he started working out again. He eased back into exercise with moderate strength training for a couple of weeks. Then he felt ready to get back into the pool.
During a workout that should have been relatively easy for him, he says, “My heart was pounding. After just a few intervals, I was gasping for breath.” While he swam, he felt a particular kind of muscle soreness that he knew, from a career in fitness, meant his muscles weren’t getting enough oxygen.
“Workout by workout, I wasn’t progressing as quickly — in terms of my cardiovascular endurance — as I would have expected. I still struggle to swim 500 yards.”
The racing heart and shortness of breath, even while exercising, can be signs of myocarditis, a potentially life-threatening inflammation of the heart typically caused by a virus. Other symptoms include chest pain, especially when lying down; swelling in your legs, ankles, or feet; and fatigue. Myocarditis can go away on its own with rest. But, elite athlete-level exercise before the heart has had time to recover can make it worse — even deadly.
“For athletes, myocarditis is a common cause of sudden cardiac arrest or sudden cardiac death,” Jonathan Kim, MD, chief of sports cardiology at Emory Healthcare in Atlanta, said at a news conference.
When an athlete has confirmed myocarditis, doctors typically recommend 3 full months of rest before returning to intense workouts. That’s why the Boston Red Sox had to sideline their pitcher for the rest of the season.
The American College of Cardiology Sports and Exercise Council recently proposed guidelines for athletes who’ve had COVID-19. The group recommends that they get an electrocardiogram (or EKG, a test that detects the heart’s electrical activity and can show arrhythmia or signs of heart damage), an echocardiogram (an ultrasound of the heart, which can look at heart function or structural damage), and bloodwork to make sure the heart is working properly before they get back to practice.
“If all those are normal,” Kim said, “it would be reasonable to allow the athlete back to training.”
Anyone Is at Risk
But it may not take an Olympic-level workout to damage the heart after COVID-19.
Preliminary data suggests that up to 1 in 5 people who go to the hospital for the virus end up with some sort of heart injury. “This injury is defined several ways: worsened heart function, arrhythmias, or a release of cardiac troponin [a sign of heart injury that a blood test can detect],” Kim said.
And new research suggests that people who don’t go to the hospital may end up with heart damage, too. In a study, researchers kept track of 100 people, ages 49 to 53, who had had COVID-19. Just over 30 of them had needed to go to the hospital for their illness, and almost 70 had recovered at home. This matters, because doctors tend to consider those who recover at home without medical care “mild to moderate” cases. But more than a month after their COVID-19 diagnosis, almost 80 people had signs of heart damage, including visible changes on an MRI; abnormal bloodwork; and inflammation of the heart.
In the grand scheme of things, a study of 100 people is not a lot of evidence, but according to doctors who analyzed the study, 80% is still too many to ignore. The bottom line is that doctors don’t have enough information yet to describe exactly who is at risk of heart injury, how high that risk may be, and how far the effects may reach. But signs are pointing to some level of risk for anyone who gets the virus.
“We are still learning as we go,” Chung says. “I’m hoping over the next several months, we’ll have enough experience and enough reports about who may be at higher risk.”
As for the 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, somebody engaged in guideline-recommended doses of exercise, slowly build up. Don’t just get back to exercise as if you had a cold. Ramp up slowly, and if there are any concerning symptoms, back down and reach out to a medical professional.”
Though he was aware of the heart risk, Koontz modified his workouts rather than cutting them out altogether. Today, he says his workouts are getting easier and he’s starting to feel more like his old self.
But COVID-19 taught him a hard lesson.
“I’ve always thought I could fix everything with diet and exercise,” he says. “Now, I hear people saying, ‘I’m fit, I’m healthy, I’m young, this won’t happen to me.’ This can happen to everybody. And the long-term effects are way more concerning to me right now than death.”
Ken Koontz, COVID-19 survivor, Woodstock, GA.
Eugene Chung, MD, director, sports cardiology, University of Michigan Medicine Frankel Cardiovascular Center, Ann Arbor.
Jonathan Kim, MD, chief, sports cardiology, Emory University, Atlanta.
Mayo Clinic: “Myocarditis.”
JAMA Cardiology: “Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19).”
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