After Yangkang, will exercise lead to sudden death from myocarditis? How long can I exercise?

Can I resume exercise immediately after “Yang Kang”? Will strenuous exercise induce myocarditis and lead to death?

Recently, there have been rumors online that some "positive" recovered patients started strenuous exercise shortly after recovery and subsequently died suddenly due to myocarditis. Can this really happen? How long after being infected with the new coronavirus can you exercise? Why do some people die suddenly after exercising after recovering from the disease?

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Getting sick is a minor matter, but life is a major matter. Moreover, among the sudden death cases spread on the Internet, there are many middle-aged and young people who seem healthy and have no underlying diseases. Although there is a lack of more research data and it is impossible to determine the exact cause of death in each case, there are still some tendencies in the medical community. There is nothing new under the sun. Even if it is a new virus strain, it has been studied for three years.

In fact, even if a person has not studied medicine, as long as he cares about his health, he may have heard of "viral myocarditis". Myocarditis is an inflammatory disease that mainly occurs in the myocardium. The most common pathogen causing myocarditis is a virus. Currently, more than 30 viruses are known to cause myocardial damage, including the influenza virus we are familiar with, and the new coronavirus is of course one of them.

Fortunately, most cases of myocarditis have a good prognosis and can be cured. However, due to the complex clinical manifestations of acute viral myocarditis, it is also easy to misdiagnose and miss the diagnosis - mild cases may have no symptoms at all, and severe cases may lead to sudden death.

The causes of viral myocarditis include bacterial infection, malnutrition, strenuous exercise, excessive fatigue, pregnancy, and hypoxia. In the statistics of sudden death autopsies, the detection rate of myocarditis is second only to coronary heart disease. [1] Therefore, it is very important to recognize this disease, increase understanding of it, and pay attention to it in life.

The pathophysiology of COVID-19-related myocarditis is thought to be a combination of direct viral damage and cardiac damage caused by the host immune response. This myocardial inflammatory disease is classified as acute, chronic, or fulminant. Among them, fulminant myocarditis is a sudden and severe disease that can lead to acute heart failure, cardiogenic shock, and life-threatening arrhythmias.

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Virus damage to the myocardium can occur during infection or some time after infection. Some cases require 1-2 months of rest and treatment before all tests return to normal. Some cases that are not properly treated will have a chronic progressive progression. Especially during the peak of infection, it is impossible to conduct detailed examinations on all infected people, and some patients may undoubtedly be missed. This is indeed a difficult enemy we face.

According to data from the United States, the number of hospitalizations for myocarditis in 2020 was 42.3% higher than in 2019. Between March 2020 and January 2021, the risk of myocarditis in patients with COVID-19 was nearly 16 times that of uninfected people, and the risk varied by gender and age. It is worth noting that the association between COVID-19 and myocarditis was most evident in children and the elderly, and more common in men than in women. [2]

Another study of 70 patients found that 67% developed myocarditis during infection and 33% developed myocarditis after infection. The average time between infection and myocarditis was 52 days. 17% of patients died, 73% were male, the average age was 44 years, and 33% had no prior medical history. [3]

In fact, even the mRNA COVID-19 vaccine has been associated with myocarditis, which can be observed in some young men aged 18-35 years after the second dose of this vaccine. However, the myocarditis observed through this route is generally mild and not as severe as typical myocarditis or COVID-19-related myocarditis, and the prognosis is better. Of course, don't worry too much when you see this news. Because this is an "extremely rare serious adverse event" of the mRNA COVID-19 vaccine, it is still recommended to be vaccinated considering the obvious benefits of the vaccine in reducing hospitalizations and deaths caused by the new coronavirus. Both the EMA and the FDA agree that the benefits of all authorized COVID-19 vaccines continue to outweigh their risks.

In this case, many people will inevitably wonder, how long after "Yang Kang" can they exercise?

If you do not have myocarditis, resuming exercise is undoubtedly safe, as long as you do it within your ability and within your tolerance, it will not bring more risks. However, if you have missed myocarditis, or if you suspect you have this problem but it is too late for further diagnosis and treatment, then you need to be more conservative about exercise.

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The World Health Organization (WHO) provides guidance on "physical activity and exercise" in the "Rehabilitation Guide" (Second Edition). Related guidance suggestions:

If you experience increased fatigue and other symptoms after a little activity, you have experienced post-exertional malaise (PEM). This condition usually occurs within hours or days after physical or mental exertion. When this occurs, you should avoid exercise and activities that cause PEM to effectively conserve energy.

If PEM does not occur after activity, activity and training can be gradually increased to improve health.[4]

To sum up

1. Myocarditis is more common in sudden death caused by cardiovascular reasons.

2. The causes of viral myocarditis include bacterial infection, malnutrition, strenuous exercise, excessive fatigue, pregnancy and hypoxia, etc. Fever, fatigue, heart symptoms, etc. often occur after upper respiratory tract or intestinal infection, which is easy to misdiagnose and miss.

3. Viral myocarditis can occur in previously healthy people, more often in men than in women.

4. If you have the above-mentioned causes and symptoms, you must rest and go to the hospital for examination as soon as possible.

References:

[1] Emergency Internal Medicine, 4th edition, People's Medical Publishing House.

[2] Association Between COVID-19 and Myocarditis Using Hospital-Based Administrative Data — United States, March 2020–January 2021https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e5.htm

[3] COVID-19 Related Myocarditis in Adults: A Systematic Review of Case Reportshttps://www.mdpi.com/2077-0383/11/19/5519

[4] https://apps.who.int/iris/bitstream/handle/10665/349695/WHO-EURO-2021-855-40590-62244-chi.pdf?sequence=1&isAllowed=y

Author: Dr. Yunyun Xu

Reviewer: Cheng Caihua, Associate Chief Physician of Cardiac Surgery, Tongji Hospital, Tongji Medical College, University of Science and Technology of China

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