Clinically relevant myocardial injury, defined by a cardiac specific troponin level exceeding the 99th percentile, is common among patients hospitalized with SARS2-Corona-19 (COVID-19) infection (1). Although incompletely understood, COVID-19 infection appears to precipitate cardiovascular injury through multiple synergistic mechanisms including direct cytokine and catecholamine chemotoxicity, microvascular and endocardial thrombosis, lymphocytic and macrophagic infiltration, and myocarditis secondary to direct viral invasion (1). Although the exact pathophysiology remains murky, the prognostic implications are clear with COVID-19 cardiac injury now a well-established predictor of disease severity and mortality (2). These important lessons have emerged almost exclusively from the clinical care of moderate-to-severely ill COVID-19 patients, an older population with a significant burden of underlying pre-existing disease. At present, the prevalence, phenotypic characteristics, and clinical relevance of myocardial injury among the millions of people worldwide infected with COVID-19 with asymptomatic or mild infectious courses remains unknown. These fundamental uncertainties are particularly relevant to young competitive athletes returning to sport after COVID-19 infection because myocarditis is a well-recognized cause of sudden death during exercise (3). Concerns about athlete safety following COVID-19 infection emerged early during the viral pandemic as numerous sporting organizations sought to resume activity, leading to a series of clinical practice recommendations designed to detect at risk athletes (4). These recommendations, first based solely on expert opinion (5), but more recently driven by mounting clinical experience (6), call for symptom-driven application of multimodality testing including the use echocardiography and cardiac magnetic resonance (CMR). A consistent and prominent feature of these recommendations has been the call for the high-quality science that will be required to move from opinion to data-driven clinical care.
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