How to Return To Running Safely Post COVID infection with Dr. Ben Levine | Koopcast Episode 66

Trail and ultra runners, what is going on? What's happening? Welcome to another episode of the KoopCast. As always, I'm your host, Coach Jason Koop, and I'm thrilled to be here today. I am absolutely honored to have the distinct privilege of bringing on the esteemed Dr. Ben Levine. Dr. Levine is one of the most revered physicians, cardiologists, and researchers in the world today. He has made seminal contributions across a broad array of disciplines in the medical community, including in exercise training, in deconditioning, as well as in aging. Dr. Levine is largely responsible for our understanding of how stimuli such as spaceflight and high altitude stimulus affect human physiology. He has been a co-investigator on four different space lab missions, which shaped our understanding of how astronauts decondition while in spaceflight.

We also have Dr. Levine to thank for our original understanding of the live high, train low concept, which every athlete should be familiar with. This stemmed from his 1997 research, which pioneered the field of altitude training for endurance athletes. Dr. Levine is also a consultant to the NCAA, the NHL, the NFL, the USOPC, and USA Track and Field. And if all of that weren't enough, Dr. Levine has a particular expertise in cardiac injury stemming from exercise after infection, which is the topic of the podcast today. Chances are that you or someone you know has had COVID-19, and the range of complications stemming from this disease are vast. Some athletes are down and out for only a few days, while others, the so-called long haulers, can remain hospitalized for months.

In addition to this, there's a growing concern among cardiologists that athletes, and endurance athletes in particular, are at higher risk of severe cardiac events post-COVID infection. So much so that a special communication went out in October of 2020, in the journal of the American Medical Association, titled, Coronavirus Disease 2019 and the Athletic Heart, Emerging Perspectives on Pathology, Risks, and Return to Play. I remember distinctly when this article came out, because it was quite alarming for me as a coach, as I have had several athletes contract COVID-19, and the picture that this paper paints can easily be viewed as a dire one for athletes.

So, to cut through it all, I asked Dr. Levine, who is one of the authors of the paper, on the podcast today to discuss all of this. I hope you find this informative, to the point, and with direct and actionable advice for anyone that has contracted COVID. I encourage anyone listening to share this podcast with your friends and training partners that have fallen victim to this incredibly tragic disease. And finally, as a piece of completely irrelevant personal history, Dr. Levine performed a stress test on me in 1995, when I was just a teenager, and he actually found those old charts. I promise the nostalgia does not last for long, but we pick up the conversation right there. So let's get right into it.

Here's my conversation with the esteemed Dr. Ben Levine about the athlete's heart post COVID-19 infection. I'm kind of floored that you, A, that you still have it, but B, that you took the time to go and find it. You know, I've got your lactates, you know, four and a half, 4.7. And what I said here is, you had a 404 PR in 1500 meters in cross country, 1640 in 5K. And, you know, I don't really, I think you were having a little chest pain or some exercise intolerance.

This is when you were, how old, 16? Is that true? I couldn't have been 15 or 16, Dr. Levine. That's a long time ago. Here's your exercise flow volume loops. But it all checked out okay and I lived. I lived and I'm still an endurance athlete 26 years later. Yep. Anyway, there you go. Thank you for entertaining me with that, Ben. I really, I really appreciate that. We pulled it out of the archives. Oh my goodness. That's hilarious, man. And all the pages are kind of stuck together. Well, that was way before ERM. So you don't have any, you don't have any electronic records to actually lose, right? You have all the paper. Once again, I'm still shocked that you guys don't get rid of all those charts after a certain amount of time.

So we send them to Iron Mountain, which is a storage facility. A lot of places do destroy them. But to be honest with you, you know, I think people's medical record is important, you know, even if it's 10 or 20 years ago. And so I don't destroy them. I keep them. Wow. Good for you. Well, there's that little piece of common thread that we can kind of pull on initially, but we're going to talk about COVID and athletes returning, returning back to play from COVID. Because this is something that's obviously really pertinent right now. Um, we're kind of seeing the, and I'm sure you are seeing the first wave of people that have recovered from COVID start to go back into exercise, whether they're running, they're training for a marathon, they're training for a triathlon or whatever.

And I started to pick up on this as a coach, having kind of been on the field, the same thing that you picked up on this as a cardiologist. We start seeing reports in the field and we start seeing reports from patients saying, Hey, something's really not, something's really not, you know, this is not normal, I guess is the easiest way to put it. Right. And so kind of what I'd like to start out with, it was just that journey, because obviously you saw the same thing and decided, Hey, we need to look at this and we need to get some information out to people. Right. So, so I think that there are a couple of things to point out. The first is one of the earliest observations that were made during this COVID pandemic is that for people who were very sick, there was often intense cardiac involvement.

There are troponin levels. That's one of the enzymes that's involved in the cross bridging of the heart, allowing the heart to contract the way it does. When the heart gets damaged, those proteins will leak out into the blood and you can measure them. And they go really high in patients who have heart attacks, for example. And we were seeing in some of the very sickest patients, very high levels of troponin, indicating that the heart was being damaged. And over time, you know, it's turned out that about 20% of patients who are hospitalized and who are sick with COVID have evidence of inflammation or injury to the heart. I'm being a little careful of my language here because we don't exactly know what the cause of that injury is.

In that context, there is an increasing recognition that inflammation or injury to the heart may be a more common cause of death on the playing field than we had previously recognized. In military recruits, in basic training, the most common cause of sudden cardiac death is probably myocarditis and inflammation of the heart muscle. And we're learning that instead of these inherited disorders of the heart in young people under the age of 30, that there is an increasing recognition that some sort of a viral infection or inflammation of the heart may be a previously unrecognized cause of cardiac arrest.

Maybe 1% or 2% of people who get the flu or other viral infections, they have some subtle evidence of heart involvement. So this is not necessarily unique to COVID. It's probably true with all viral illnesses. But with COVID, it seems to be pretty aggressive. And we did an interesting study. It hasn't yet been published with a group in New York City who looked at the fire department in New York who looked at the rates of out-of-hospital cardiac arrest in New York City during the pandemic. And their initial reports published in the medical literature show a marked increase in the rate of out-of-hospital cardiac arrest. But that's like most of that is older people not coming to the hospital and dying of their heart attacks at home.

So I went to them and said, okay, let's look only at people 18 to 35 because it's unlikely that they're having heart attacks at home. And it turns out there's an almost doubling of the rate of cardiac arrest. Now, it's not like it's that high. It's only 5 per 100,000, right? So it's not like people are dropping like flies. But it is something that raised our concern that maybe COVID could be increasing the risk during sports. Because during exercise, you put a big demand on the heart. The heart has to contract, expand, and contract. And the heart rate goes up. You've got to pump all this blood out to the skeletal muscle. And you pour out all this adrenaline and noradrenaline.

And that is arrhythmogenic. And so anyway, I think that set the stage for our concern and trying to come up with some guidelines. And we did that back in May. We did some general. Aaron Baggish and I talked about the Icarus phenomenon. You know, how do you deal with this? Do you say, oh, don't worry about it and fly too close to the sun? Or do you not fly high enough and just drop into the ground? And so we raised this issue and put out some guidelines. And over the course of the summer, as a lot of people started to recover from COVID, a lot of athletes that come back to university and started to have to compete.

And we had to worry about not just viral spread, but what are the consequences of COVID? And universities and sports conferences were coming up with, trying to come up with guidelines. What do we do? You know, do we just let people play? Do we get an EKG? Do we get a troponin? Do we get an echo? Do they all need an MRI? What do we do? And each conference came up with their own strategy. And it turned out that we were doing a lot of testing and we weren't finding anything. I mean, and the stuff that we were finding was not especially compelling. So this group of sports cardiologists got together again this fall. And we said, you know, we've got to dig back into this literature, see what's been published, and try to make some a little bit more rational guidelines.

Not everybody who's ever had COVID needs to get an extraordinary evaluation. Now, I will say some leagues are still requiring it. You know, the Big 12, for example, here in North Texas, where I am, everybody with COVID gets a troponin, an EKG, and an echo, even if they're asymptomatic. And so we've sort of worked with the sports medicine doctors trying to figure out how to avoid hurting people by picking up incidental things and really making sure that the people we're identifying are people who we have concerns about. So that's how this whole process evolved. And, you know, we continue to learn a lot about it. You know, since this article was published, there's been new data from West Virginia.

There's been a group from Wisconsin. There's been a new publication just a couple of weeks ago from Vanderbilt, the only actually controlled study. And so, and what typically happens, particularly in the COVID world, is the first blush of data in small numbers, you know, gets everybody agitated. And people are trying to publish it quickly. Let's get this out there. And then as we get a little more experience, we realize that's a selected group, not the whole story. And I think that, you know, the larger studies, the ones that are more controlled, are showing that the risk of myocarditis or cardiac injury in athletes who've had COVID is pretty small.

It's certainly less than 5% and probably closer to one, no more than 2%. We do have a big registry with the NCAA looking at over 3,000 athletes. And that data, those data are still being accumulated. But I think that it's real, it's present, but it's not as common or catastrophic as we were worried about early on in the pandemic. That's really interesting. So just to set the table for the listeners, how does that rate compare to just the normal, like a normal healthy athletic population? If you were to go and to look at that amongst the NCAA athletes that you mentioned earlier, how does that compare? How does what, the rate of myocarditis?

Correct. Yeah. We have no idea. That's part of the problem. Right. Right. Because no one's doing troponins and on every single NCAA athlete. Right. And so I think that, and certainly no one's doing cardiac MRIs on every NCAA athlete who doesn't have COVID because that's pretty pricey. So I guess that that number would be much smaller. But would it be much smaller than somebody, if we looked at every athlete with the flu? That I'm not so certain. And this may be a natural consequence of a serious viral illness that's particularly that spreads throughout the body.

And, you know, the mantra in the sports medicine world is if somebody is sick, if the symptoms are above the neck, you don't have to worry so much. If they're below the neck, cough, chest pain, shortness of breath, fever, you should don't exercise that day. You know, take it easy. And in many ways, that's playing out in the COVID world too. You know, that was one of the things we didn't do well in the initial guidelines is help the sports medicine docs say, well, what's mild? What's moderate? What does that even mean? And so our current guidelines, which I'm sure you've read, have said that if people are completely asymptomatic, and remember, many of these leagues are testing their athletes, you know, two, three, four times a week to avoid a catastrophic spread within the community.

So if they're asymptomatic and it's just detected on a random test, or they have mild symptoms, and we're calling those symptoms above the neck. You know, you lose your sense of taste or smell. That's a pretty specific one. Little congestion, a headache, low-grade fever for a day or so, short-lived. We consider that mild symptoms, and we are not recommending that those people get a comprehensive cardiac workout. We think they have to, you know, quarantine, of course, for at least 10 days from the onset or the symptoms or the test if it's asymptomatic, and then gradually return to play. For more with advanced testing, only if they have trouble when they come back.

For people who are sicker, you know, fever that lasts, you know, four or five days, severe muscle aches, coughing, some shortness of breath, those people need to be worked up. And we are recommending that everybody get at least an electrocardiogram, ECG or EKG, either one's the same thing. A troponin measurement, which is a blood test. And then an echocardiogram to begin with. And our recommendation is that for most of those, if that's normal, that they can start a return to play process. Here's the confounding thing with that, though. And you know this just as well as I do, is athletes' hearts are weird. And we see this particularly in the endurance community.

And so if you have an endurance athlete out there, and they have these severe symptoms that you were just talking about, below the neck symptoms, fever for four or five days, lethargy for seven or eight days, or whatever it is, whatever combination of all those there is, they go in and they get this battery of tests for the first time. They don't know if those results are weird to them or not. But a cardiologist on the other side of it goes, oh man, this doesn't look right. Absolutely. I think this is the big problem, right? And we've had multiple other guidelines about how to evaluate these tests in athletes, right? So let's pick troponin, right, which is the, we talked about at the beginning, the measure in the blood of protein.

We know that intense exercise elevates troponin. And so what we're telling the sports medicine docs is that if the troponin is elevated, don't panic. Make sure the athlete doesn't do any exercise for at least 48 hours and then repeat it. Because it typically will go down very quickly if it's exercise related. If it's persistently elevated, well, then we have to start thinking about why that should be. Athletes have big hearts, right? Particularly endurance athletes. I mean, your community in particular are these ultra endurance athletes who are well known to have big hearts, both the right side of the heart and the left side of the heart. And we've had this big problem with our sonographers, right?

I send a six foot nine, 310 pounds, you know, big muscular basketball forward who does a lot of training and they measure the heart size is a little big and they call RV dilation. Oh my God, that's just a normal athletic heart, right? You know, and an ejection fraction that is a little bit at the lower end of normal, that's the percentage of blood that's pumped out with each heartbeat. Typically it's, you know, 55 to 65% or 70%. Athletes, because their hearts are so big, they don't need to pump as much. Right. So it may be closer to 50 or even 48, you know? And so that's not the time to panic, right?

Right. Because there are other measures that we can look at that hopefully people will understand. You look at the relative size of the two hearts. You look at their diastolic function, something called strain or strain imaging. You see what happens during exercise. So you're absolutely right imaging. And then, I mean, we're using MRI as the gold standard, right? But we know that a substantial portion of particularly masters, ultra endurance athletes, will have some abnormalities of the right ventricle in particular. And, you know, the right ventricle and the left ventricle are connected to each other. And the left ventricle spins like this and the right ventricle contracts like this. And so right at that hinge point, it often can get a little swollen, maybe a little scarred.

And that's not uncommon. Maybe 25% of endurance masters, endurance athletes will have it. We don't know that data in young college athletes. But the Vanderbilt data from just a few weeks ago said maybe 20, 25% even of college athletes. Interesting. So we can't use that as a sign of myocarditis. And so this is challenging and requires, you know, to understand what's the clinical scenario. So if I've got an athlete who had COVID, they were sick for a few days, but they feel fine. They've got some minor abnormalities. I might do a little extra testing. I might do a stress test. I might do some monitoring for a week or so. Make sure they're not having an arrhythmia.

You know, we're still learning about this disease. You know, I don't want to be cavalier. You know, I think we have to take it seriously. We've had, you know, almost 430,000 deaths in the United States. This is a big deal from this virus. You know, I personally work in the intensive care unit. I take care of these patients. It's a terrible disease. And we have to take it very, very seriously. That being said, probably a third of people who get COVID never even know they have it. They're asymptomatic. So these are the challenges in figuring out what to do here. So one of the takeaways that I think the listeners need to kind of come away with is it's kind of along two prongs. The first one is, is if you have these below the neck symptoms and you've had COVID and you're an active athlete, it's probably worth getting, you know, getting a workup done based on your recommendations.

The second part of it is, is if those rec, if that workout comes back with something that's off, something that's weird, something that is a cause for concern. It is, it might not be cause for panic, but cause to look a little bit deeper. Exactly. Exactly. I think that's really well said. It's not time to panic. It's time to get a little bit more information, you know, a lot. And then athletes, as you know, they get very agitated if someone tells them they can't train. And so what I tell a lot of my athletes is, look, if you just tore your ACL or if you had a bad ankle sprain, you wouldn't be fussing me. Right. Right. You wouldn't be going out and running a trail run if you just had a high ankle sprain and could barely walk and were on crutches.

So take your heart at least as seriously as you would take an ankle sprain. Okay. See a doctor, see a good doctor who knows what they're doing. If it, if it requires a little bit of delay time to do the appropriate workup and make sure you're okay, do that. But, and then if it's something serious, you want to know that. Absolutely. A hundred percent. So this is, this is going to, I think it's going to unfold in your world relatively rapidly, maybe during the third or fourth quarter of this year, 2021. As the big mass participation events start to come back online. We know the Boston marathon is not going to happen. You look at these big, huge marathons, big, huge triathlons and other types of endurance events.

They just can't operate right now. But once they come back online and once the athletes start training for those, that's when they're going to see the rush of people come in for all of these screens. So you're going to have a bigger data set there. So I don't know if you've like thought about what that means in terms of this outstanding question that you mentioned earlier that you really don't know, right? You really don't know what this is going to look like six months from now or nine months from now. Yeah, no, those are great questions, Jason. And I think it raises a couple of issues. First, I mean, I'm one of the advisors to the USA Track and Field and the USA Olympic Committee. So, in fact, just today we've been emailing about the Olympic, about preparation for Olympic trials.

And what do we, what is the implication of vaccines for athletes and spectators? And we've established protocols for safe participation. But, I mean, we tried to come up with a way to have safe indoor season. We couldn't do it. We just couldn't come up with a way to do it. You know, but exercise outdoors is better than indoors. You know, larger separation is better than shorter separation. You know, short contact time is better than long contact time. These are the things that increase the risk of spread. And so, you know, I think we've come up with guidelines to be reasonably safe for participating events. At least, you know, we're not talking about 40,000 people running, you know, the New York Marathon, of course.

You know, it's hard to stagger those well enough to minimize contact time, right? So, I think that the other issue, though, that we haven't talked about is what's being called the long haulers, right? That is, people who've had COVID, maybe didn't even get that sick, but they never completely recovered. And we're still learning about what that means. How much of it is related to, you know, let's say they were knocked down and went to bed for, you know, a week or so. How much of it is the bed rest deconditioning effect? How much of it is some residual injury to the lungs or the heart or the skeletal muscle or the autonomic nervous system, the part of the brain that links all those together?

We have a long haulers clinic here at UT Southwestern in the Department of Physical Medicine and Rehabilitation. And we're just starting to do basic autonomic function testing on all our long haulers. You know, that's different than, you know, elite athletes that are most of your listeners. But on the other hand, you know, an athlete may detect a small change in performance before a sedentary person. So, you know, if you're typically used to running, let's say if we're talking about an ultra marathon, let's say you're used to running, you know, seven minute pace, right, or eight minute pace. And all of a sudden, you can't do that anymore. And you're running 10 minute pace or 11 minute pace. And you say, I just can't go any faster.

You know, why is that? And how much of that is, could be related to residual chronic effects of the virus? And how much of it is other effects of how it impacted your training and intervened, stuck itself into the middle of that process? Do you think that endurance athletes in particular are any more or less susceptible to this long hauler syndrome? Or is it just way too early to tell? Yeah, I don't see any reason why they would. You know, there's a few, some sense that perhaps intense and prolonged endurance exercise may reduce certain kinds of immunity. You know, so it's possible, particularly if they're doing, you know, 20, 30 hours a week of training.

You know, that's certainly possible. People who are overtrained and, you know, some of your listeners out there are, even though they don't know it. A hundred percent. And they probably have somewhat diminished immunity and might be a little bit more susceptible. So we just don't know the answer to it. And of course, the athletes are very sensitive to their bodies. You know, they know what it's like. This is the whole issue of pacing, right? I mean, most of your runners, we want to tell you, they can get out on a track and depending on their skill, they can knock off 10 60 second quarters or 10 70 second quarters or 10 80 second quarters, whatever that happens to be. But they know what that feels like.

You know, and they can do it every single time. They don't need a pacer. And get out and do it. And they don't even need to look at their watch. You know, so how is it that you, you know, you sense how fast you're moving across the ground, what your muscles feel like, how hard your heart's beating, how hard you're breathing. These are the kind of environmental and internal sensations that athletes use to gauge pace. And how those come off and start to deteriorate with chronic illness, you know, we just don't know in this circumstance. The listeners will remember I had Glenn Davison on the podcast several weeks ago when the pandemic just erupted. He made a pretty funny comment to me that he's like, this is the one time in my entire career where I'm the most popular person in the room.

Two years from now, nobody's going to care about me. But his point was in the whole podcast was just about immunity and how exercise can affect immunity and things like that. And endurance athletes are susceptible to this because we go through these big changes in our training load that can absolutely drive down our immunity. But it's one thing to drive down your immunity and have a consequence of that be more susceptible to catching a disease. But am I hearing from you that that also might contribute possibly, or do we not know this as well, to becoming a long hauler, meaning your immune system is just not functioning well enough and that might put you in that category?

Well, I think we just don't know. And this is a bit of a double-edged sword. So I will say that you can read a thousand articles on changes in immunity with endurance exercise, right? And same thing with spaceflight. But you can't find a thousand articles showing that athletes or astronauts get a lot of infections, you know, that they have more systemic infections than others. So what we measure in the blood or in the, you know, cell culture or whatever is not always clearly linked to what's happening in the entire whole animal. So it is possible that they could be more susceptible.

On the other hand, remember that the most serious consequences of COVID are probably the immune response to it. So this cytokine storm and overwhelming immune response that is the body's way of fighting off the virus that actually causes a lot of the damage, particularly in younger people and kids. It's called the MISC, Multisystem Inflammatory Syndrome in children. We realize that it's not limited to children. And that's why it's that second week after the infection that the serious symptoms start to kick in.

And why we really want people to wait at least 10 days. I must say, you know, that when the CDC changed their recommendations from 14 to 10, that was mostly geared on spread of the virus, not on what happened inside your body. So I'm, you know, although our guidelines say 10 days from a positive test result or 10 days from symptom onset and full resolution of symptoms. I'm still a little bit cautious, you know, in that second week. And I want people, when they go back to return to play, those first few days should be relatively easy. I'm on board with both of those recommendations from a coaching perspective.

Because one, it's two days or three days or maybe even four days. And you know this. Big fucking deal, right? Yeah, exactly. That's exactly what I tell my athletes. Dr. Levine, I'm so glad to hear that from you. In the entire context of training, which is hundreds and thousands of days, those few days are not material in the whole. And you've got a five-year, I don't know who you're coaching, but you often will have a five-year, three-year, one-year macro cycle, depending on what your targets are. And those four days, oh, my God. You know, if you stepped on something and had, you know, a blister, the athlete wouldn't say, oh, my God, I'm getting back. Right?

But we both know, and you've seen this in your practice, athletes are always chomping at the bit, like, tell me the exact hour that I can go back and start exercising again. But I think anybody who's listening to this podcast that has had COVID, I think would be wise to take these two pieces of counsel under advice. First one is wait a little bit longer than you think you need to. There's a 10-day guideline, but if you wait an extra few days, it is not going to be material to whatever race you're training for. I can vouch for that as a coach. I just know how that happens. And the second thing, and I want you to pick up on this, is that the return to training is easy. The first day out of the gate, you're not hammering 400-meter repeats or anything like that, which you want to do because you've just taken 10 or 14 days off.

The first days back are easy, right? It's sort of like, you know, I don't know how many of your athletes do altitude training, Jason. A lot of them, yeah. It's one of my other great loves and areas of expertise, but, you know, the easiest way to hurt an athlete is to take them altitude and have them blast the first four days, right? You'll overtrain them almost instantaneously. So, you know, you think about it just like going to altitude or going into a hot environment, getting some heat acclimatization. Those first few days have to be easy. And they know that from other experience. So, you know, that's a wise recommendation that you just need. Ben, this is why I wanted to talk to you about it. Because with all due respect to all the other cardiologists out there, like because of your altitude background and because that you've worked with a tremendous amount of athletes in all different types of sports, particularly in running, you understand the psyche of the athletes having worked with them and can blend these two areas very well.

Which is not easy. Right. But, you know, it's why there's a whole field of sports cardiology. Right. There are a number of them, you know, obviously I'm not unique. You know, Paul Thompson, for example, was U.S. Olympic trial runner and one of the guys, probably the godfather of our field. You know, Aaron Bagish is the, you know, director of the Boston Marathon and, you know, is a two hour marathoner, you know, two under 230 marathoner himself. You know, and so there are a lot of great people who know the business, but there are not hundreds of thousands of them. And so I think many athletes, you know, often are comfortable if the cardiologist, they can be confident that the cardiologist understands their objectives, their goals.

And, you know, I have this conversation with every athlete, regardless of why I see them. The first, you know, part of my interview with them is, tell me about your treatment. What are your macro cycles? What are your mesocycles? What kind of micro cycles do you do? How much long, slow distance? How much, you know, speed work do you do? And then why do you do it? What's your motivation? You know, this is pretty clear when you've got, you know, college athlete, when they've got, you know, an NBA career on the line or an NFL career on the line. And a master's athlete, you know, is your goal that you want to, you know, you want to do a 230 marathon at the age of 45 and qualify.

You need to qualify for Boston. Are you looking for world championships? I've got a 75-year-old guy with heart here who's top guy in the world in his age group. Wow. You know, in sprint triathlon. This is his, it's his identity. It's the most important thing for him in the world. And so that's different from the guy who just wants to get out there and, you know, run a fun run with their grandkids. Yep. And that's interesting context because I know a lot of people that are going to go in for these screenings after having listened to this or having come across the paper that you wrote and taking the advice in it. They're not going to have those goals in the back of their head. Their goal is to find an answer that will tell them if they can go out and train hard the next day.

That's their goal. That's their immediate goal going into it. And another thing that I'm hearing from you is, is irrespective of the cardiologist that you're seeing, the cardiologist is like you. They're asking those questions. But to take a step back and ask yourself, what are the bigger goals that I want to accomplish? Not only in athletics and running, but with this specific test that I'm getting or tests that I'm going to have run. Yep. Yep. I agree. That's right. Oh, okay. Let's wrap it up. So we're going to have, let's kind of put ourselves in the, in the shoes, the running shoes, trail running shoes of the listeners out there that have a training partner. They themselves or a loved one that has had COVID and they're just starting to come back into training.

What would you tell that person that's good, that wants to come back and train, that's, that thinks that they might have some issue that they know that they need to get screened for? Great. Great. Well, the first thing is to know whether you've had COVID or not, right? So I think there, it gets us a little bit into the testing realm. So as you know, you can be tested with a PCR test, a polymerase gene reaction, which measures the molecular components of the virus. And that's the one where they stick the nasal swab up into your brain and leave there for 10 seconds. And, you know, that is a very sensitive and specific test, but it's not infallible.

You know, and if somebody has a lot of symptoms that are suggestive of COVID and the first test is negative, it's worth getting a second test. There's also the antigen test, which is the quick test, right? The PCR generally takes a little bit of time. The antigen tests are the ones that are the point of care testing. They take only a few minutes. They're measuring viral proteins. It's not the molecular response. And if it's positive, you got it for sure, right? It's not as sensitive though. And if you're worried that you might actually have it, then it's probably not the best test for you. If you're in a low pre-test probability environment, so you haven't had a big exposure, you're really not worried about it.

It's a low risk exposure. The antigen test is probably just fine, right? But if you're worried and the risk is high, then a negative antigen test might not reassure you, right? And then there's the antibody tests. The antibody tests don't tell you whether you have it now. They tell you whether you've been exposed and had it in the past. So somebody who has had a loved one or a training partner who's been positive, who's waited that 10 days and is unlikely to be infectious anymore, and who feels well, but they feel they really want to know whether they had been exposed to COVID, then the antibody test is a good one.

You know, even if their PCR is negative, then the antibody test will tell them whether they've been exposed or not. So there are two sort of different issues. One is, did you have COVID and have you been exposed to that? And then what are the consequences of that infection for your performance? And so my own bias is if you've been asymptomatic and you don't think you had it and you feel fine, you know, those are not people in my mind who need an extensive amount of screening. And even if you've been positive, like your wife had it and, you know, or your husband had it and you've been, you get a test and you, just because of the exposure and it's positive, but you feel fine.

You know, I would still wait those 10 days from the positive test. That's what our recommendations are, right? But then I, and then I would take, you know, a couple of days to get back into training slowly, like going to altitude, but I wouldn't go see a cardiologist for troponin and an EKG and the echo. I think that would be overkill. And then for the athletes that are in the severe symptoms category, that's when they're bringing out additional tests and things like that. Yeah. I think those athletes, if you've been sick for a week and you had fever, you know, a high fever for four or five days and you've been coughing and you're still coughing and you turn out to have COVID that, you know, you need to get more testing before you're ready to go back into training.

And then what for the, for the people in the last group, they go in and they get more testing and they find that something is awry. Do they then fall into more of a standard care of treatment or is it different because we don't know as much about the consequences of COVID? Right. So, so, so the answer to that is also twofold. So number one, what we don't know is what's the risk of sudden cardiac death or worsening cardiac function by continuing to train in the face of COVID infection of the heart. So, you know, let's just, let's take the extreme circumstance, right? Someone was pretty sick, almost had to be hospitalized, you know, high fever, clearly sick with COVID.

Their troponin is elevated, their echo shows, you know, LV function that's, that's not normal and their EKG is abnormal. Well, that's a patient I would get an MRI on. If that showed myocarditis, I would say, look, you're going to, you're not training for three months. Okay. And, and I'm so sorry to hear that, but it's just as if you torn your ACL and you were undergoing surgery. It's exactly the same thing. You are not going to be able to train for three months. I'm sorry. Work on, yeah, work on, you know, the intellectual side of your sport, read everything about it, you know, start to talk to other coaches, get smarter, you know, work on yoga and balance and some, some, some body type strength, but you're not doing any intense exercise for three months.

And after three months, I would repeat many of those studies. And if the troponin is normal and the EKG and echo has returned to normal, I probably wouldn't do a repeat MRI, but I'd say, okay, you're three months out now, let's start develop a return to play clinic. And, you know, we do some easy running or biking to begin with and let's see how you do maybe every other day for the first week. And if, as you come back and you start to feel stronger, you know, we'll have a follow-up plan. You know, we might repeat the echo again in three months to make sure that as you return to play, you weren't hurting yourself. I'd buy you an exercise test, an intense exercise test to make sure that you weren't having any arrhythmias.

I might put a patch monitor on you to make sure that as you're going through your training, you're not getting anything that would worry me that you're putting your life or your heart in danger. So, so the sicker you were, the greater my worry, the more the testing and the closer to follow up. I love the orthopedic analogy that you've used a couple of times where it's just like a torn Achilles or an MCL tear or something like that. Except for, I think this is an important clarification, the penalty for further failure in a cardiac event is way more severe than tearing your Achilles. Right. Well, the thing with tearing your Achilles is you simply can't do it. Right. And that's where the cardiac stuff can fool people because you may be able to do it and work hard enough to hurt yourself.

If your leg's in a cast and you just had surgery, you ain't running up a mountain. Right. It doesn't matter how much you want to. And so that's why I use that analogy because I say, you wouldn't be fussing me at all if you just had a serious orthopedic injury. Right. Right. You would just say, okay, I've got to heal and then I'll come back. Yeah. It doesn't mean everybody who gets an injury, their career is not over. Right. A hundred percent. Right. Right. The body will heal itself. Right. Eventually give us some rest. Okay. We're going to let you go. Dr. Levine, thanks for entertaining everybody. Thanks for entertaining me and pulling up those, pulling up all those old studies from 26 years ago. I'm floored that you still, that you still have them right there. Jason Koop. There he is.

Absolutely. Oh my gosh. Unbelievable. Nice to see you. Glad you're doing so well. And nice to meet your listeners. And let me know when the whole podcast is put together. I will. Absolutely. I'll include links in the show notes to the paper that, the paper that you wrote. And if there's anything else after the fact that you want me to include, they are just resources for people. I'm more than happy to include those also. All right. Great. Take care. Yep. Take care. Bye. All right, runners. There you have it. There you go. Much thanks to Dr. Levine for coming on the podcast today and discussing this incredibly important topic. For any of you listening that have had training partners or your friends or family that have had COVID-19 and are wondering about how they can safely reincorporate exercise in their routine.

Go ahead. Share this podcast with them. I hope that it puts some of their mind at ease about some of the risks that are there after somebody has contracted this disease. That's it for the podcast today, you guys. Appreciate the heck out of each and every one of you. And we will see you out on the trails. Thank you.