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Received date: 23/05/2025 Published date: 12/06/2025 Case Report

A Brief Overview of Myocarditis

Massimo Bolognesi MD*

Centre for Internal and Sports Cardiology Medicine Local Health of Romagna – District of Cesena Via Ungaretti 494 47521 Cesena (FC) Italy

*Corresponding author

Massimo Bolognesi MD, Centre for Internal and Sports Cardiology Medicine Local Health of Romagna – District of Cesena Via Ungaretti 494 47521 Cesena (FC) Italy.

DOI: 10.55920/JCRMHS.2025.11.001482

Abstract

Myocarditis is one of the main causes of sudden cardiac death (SCD) in athletes. According to current international recommendations, athletes should generally refrain from competitive sports for three to six months after experiencing myocarditis. However, this period may be extended to 12 months in complicated cases. This recommendation is based on limited evidence, primarily from autopsy studies and expert opinion. The uncertainty stems from the fact that suspending athletes for prolonged periods can disrupt their training and competitions, potentially resulting in decreased performance and an inability to compete. This brief review summarises the key principles of granting athletic clearance to athletes with myocarditis and their return to athletic activity.

Keywords: Myocarditis, Cardiac Magnetic Resonance, Athletes, Sports Pre-partecipation screening, Recommendation

Introduction

Myocarditis is an inflammatory disease of the heart, usually caused by viral infections or the body's immune response to them ¹. It is one of the most common causes of arrhythmia and sudden cardiac death (SCD) in active individuals, including athletes ². Elite athletes appear to be particularly susceptible to viral infections complicated by myocarditis due to their greater exposure to viruses, compromised immune systems and tendency to resume training prematurely following an infection ^1-3. Other risk factors include strenuous training or competition and exercising in extreme weather conditions. Therefore, accurately diagnosing the condition is a significant challenge for sports cardiologists given its broad and variable clinical presentation⁴. Athletes typically present with non-specific symptoms such as fatigue, muscle soreness, an increased heart rate at rest and during exercise, and decreased exercise tolerance ⁵. Accurate diagnosis is therefore of paramount importance.

Discussion

In addition to a resting electrocardiogram (ECG), a correct diagnosis requires cardiac biomarkers, an echocardiogram, a 24-hour ECG reading and cardiac magnetic resonance imaging (CMR) ^5-6. CMR is used to assess inflammation, oedema and fibrosis via late gadolinium enhancement (LGE). These measures are crucial for predicting prognosis and exercise capacity. CMR imaging is invaluable for accurately diagnosing myocarditis and is currently considered the most appropriate non-invasive assessment method ⁷. There is a high level of agreement between CMR and biopsy results. Furthermore, CMR provides an accurate assessment of left ventricular contractile function, as well as myocardial oedema and scar burden. In the acute phase, T2-weighted oedema imaging can identify acute myocardial inflammation. LGE imaging reveals two patterns of myocardial damage: midwall enhancement in the septal wall or patchy subepicardial distribution in the lateral wall of the left ventricle ^7-8–9. However, LGE imaging cannot distinguish between acute and chronic inflammation; it simply indicates the presence of damaged myocardium. According to international recommendations, an endomyocardial biopsy is advised for patients with inadequate cardiac recovery, in order to clarify the diagnosis and determine the most appropriate treatment ^9-10. In uncomplicated cases with normal left ventricular function during the acute phase and an absence of LGE, certification to resume sporting activities can be granted at least three months after clinical recovery. However, in cases with persistent pathological findings, the risk of sudden cardiac death (SCD) remains high even after six to 12 months.

Figure 1

The Italian COCIS 2023 recommendations on the eligibility of athletes to return to competitive sport after experiencing myocarditis are quite similar, focusing on specific aspects of the condition ¹¹. Temporary suspension from competitive sport is recommended for individuals with a definite or probable diagnosis of myocarditis. Those with clinically resolved myocarditis can resume competitive sport after three to six months. Specific recommendations are provided for cases of persistent late gadolinium enhancement (LGE) on follow-up cardiac magnetic resonance imaging (CMR), particularly in cases of non-ischaemic left ventricular scarring (NILVS) (see attached Figures). Individuals with NILVS associated with left ventricular (LV) dysfunction, significant electrocardiogram (ECG) abnormalities, and/or ventricular arrhythmias should not participate in competitive sports. However, athletes with NILVS involving fewer than three segments of the LV free wall, normal systolic function, and a normal ECG with no significant ventricular arrhythmias (as determined by maximal exercise stress testing and 24-hour ambulatory ECG monitoring during training sessions) may participate in competitive sports, provided they undergo careful evaluation at a specialist centre. The decision to participate should take into account the sport that the patient wishes to play. Patients with NILVS affecting three or more segments should not participate in competitive sports, except for skill-based disciplines. This applies even if there are no other risk markers present. The decision should be made following a thorough evaluation at a specialist centre. Speaking of which, the recent case of arrhythmogenic cardiac arrest experienced by the young Italian professional footballer Bove while playing on the pitch highlights the potential dangers of myocardial scarring following a case of Covid-19. This case is of particular importance to sports medicine physicians and sports cardiologists. Even long after the initial infection, scarring can trigger dangerous arrhythmias, as demonstrated by this case despite monitoring with MRI. Such cases emphasise the importance of recommending prolonged loop recorder monitoring for athletes at risk of arrhythmia, in order to detect any submerged arrhythmogenic burden.

Conclusions

These recommendations should enable physicians to make more informed decisions about athletes' eligibility, as well as helping them to identify those at risk of sudden death due to suspected myocarditis more effectively. They should also allow for more consistent data collection. Evidence based on large, multicentre registries, including cardiac magnetic resonance imaging and endomyocardial biopsy, is needed to modify recommendations regarding athletes' participation in sporting activities. In future, clinicians should use new combined methods of risk stratification that implement both non-invasive and invasive tissue characterisation techniques.

Conflict of interest: The author have no conflicts of interest to disclose.

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Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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