Text with master prompt, adding reference Drazner MH et al 2025.
AI Model: Sonnet 4 (Claude) on September 26th, 2025.
Expert: PD Dr. med. David Niederseer

Clinical case

A 23-year-old female elite runner, previously healthy with normal pre-participation screening, developed fatigue and an upper respiratory tract infection with fever for three days. Her symptoms improved but she continued to experience prolonged fatigue, which led her to seek evaluation by a sports and exercise medicine physician. Investigations revealed electrocardiographic changes with PR-segment depression, anterior T-wave inversion, elevated CRP and troponin levels, and a normal NT-proBNP. Transthoracic echocardiography demonstrated a pericardial effusion with preserved left ventricular systolic function. Cardiac MRI showed epicardial late gadolinium enhancement of the inferolateral wall of the left ventricle. Based on these findings, a diagnosis of acute perimyocarditis was made. She is scheduled to compete in the 5000-meter world championships in six months.
What is the proposed management, and RTP?

Introduction

As sports and exercise medicine physicians, we increasingly encounter cardiovascular complications following viral infections in athletes, particularly in the post-COVID-19 era. Acute perimyocarditis—the concurrent inflammation of both the pericardium and myocardium—represents one of the most challenging diagnostic and management scenarios in our practice. The condition demands careful clinical reasoning, as the stakes for elite athletes extend beyond immediate health concerns to career-defining competitive opportunities.
The understanding of myocarditis and pericarditis in athletes has evolved significantly over the past decade. The 2024 American College of Cardiology Expert Consensus Decision Pathway on myocarditis provides the most current evidence-based framework for diagnosis and management [1]. Recent British Journal of Sports Medicine publications on cardiorespiratory considerations for return-to-play after COVID-19 infection and the 2020 European Society of Cardiology guidelines have refined our approach to inflammatory cardiac conditions [2,3]. Current data suggests that myocarditis occurs in approximately 0.17% of competitive athletes, with viral infections being the predominant trigger [4]. However, the true incidence of perimyocarditis may be underestimated due to subclinical presentations and diagnostic challenges.

Case Reference

The elite runner presented exemplifies the complexity we face when managing inflammatory cardiac conditions in high-performance athletes. Her case highlights several critical considerations: the post-viral timeline, the diagnostic challenge of differentiating between isolated pericarditis and combined perimyocarditis, and the pressure of impending major competition. The presence of both pericardial effusion and myocardial involvement, evidenced by elevated troponin and cardiac MRI findings, transforms what might initially appear as straightforward viral pericarditis into a more complex clinical scenario requiring extended monitoring and careful return-to-play planning.

Clinical Background

Perimyocarditis represents a spectrum of inflammatory cardiac disease where both pericardial and myocardial tissues are affected. The etiology is predominantly viral, with common pathogens including coxsackievirus, echovirus, influenza, and more recently, SARS-CoV-2 [4]. The pathophysiology involves direct viral cytotoxicity and subsequent immune-mediated inflammation, which can persist beyond viral clearance.
Clinical presentation typically follows a biphasic pattern: initial viral prodrome followed by cardiac symptoms including chest pain, dyspnea, and fatigue. The diagnostic challenge lies in distinguishing between isolated pericarditis and myocardial involvement. Key diagnostic criteria include: typical chest pain, pericardial friction rub, electrocardiographic changes (PR depression, diffuse ST elevation), elevated inflammatory markers, and imaging evidence of pericardial effusion or myocardial inflammation [5].
Differential diagnosis must consider other causes of acute chest pain and elevated troponin in athletes, including exercise-induced cardiac remodeling, coronary artery disease (though rare in young athletes), pulmonary embolism, and other inflammatory conditions. The combination of clinical presentation, biomarkers, ECG changes, and advanced imaging with cardiac MRI provides the most comprehensive diagnostic approach.

Management

My approach to managing perimyocarditis in elite athletes follows a structured, evidence-based pathway involving multiple healthcare professionals. The initial management team includes the sports physician, cardiologist, and physiologist, with potential involvement of an exercise physiologist and sports psychologist depending on the severity and duration of restrictions.

Acute Phase Management: Immediate cessation of training and competition is mandatory. I prescribe anti-inflammatory therapy with colchicine (0.5mg twice daily) and NSAIDs, typically ibuprofen 600mg three times daily for 2-4 weeks [6]. Monitoring includes serial ECGs, inflammatory markers (CRP, ESR), and troponin levels. I schedule follow-up assessments at 1-2 week intervals during the acute phase.

Subacute Phase (2-8 weeks): As symptoms resolve and inflammatory markers normalize, I gradually introduce light activities of daily living while maintaining training restriction. Serial echocardiograms assess pericardial effusion resolution and ventricular function. I coordinate closely with the athlete’s coaching team to manage expectations and maintain fitness through permitted activities.

Recovery Phase (2-6 months): Once clinical resolution is achieved—defined as symptom resolution, normalized inflammatory markers, and stable imaging—I initiate a structured return-to-play protocol. This involves collaboration with the team physiologist to design a progressive exercise program starting at 50% maximum heart rate.
The multidisciplinary approach is crucial. The cardiologist provides specialized cardiac assessment and risk stratification. The exercise physiologist designs safe progression protocols, while the sports psychologist addresses the anxiety and frustration common in elite athletes facing extended competition restrictions.

Return to Play

Return-to-play decisions in perimyocarditis follow international consensus guidelines, primarily the 2015 ESC recommendations and recent evidence-based statements [7,8]. The process requires satisfaction of specific criteria before exercise resumption: complete symptom resolution for at least one week, normalized inflammatory markers (CRP <3mg/L), normal resting ECG, and stable cardiac function on echocardiography.
For elite athletes, additional considerations include advanced imaging with cardiac MRI to exclude ongoing myocardial inflammation, evidenced by absence of late gadolinium enhancement and normalized T2-weighted imaging. Exercise stress testing may be considered in selected cases, though its role remains debated [9].
The return-to-play protocol follows a graduated approach (Table 1): starting with light aerobic exercise at 50% maximum heart rate for 2 weeks, progressing to 70% for 2 weeks, then sport-specific training at 85%, before full competition clearance. Each phase requires symptom monitoring and may include repeat cardiac biomarkers.
Special considerations for elite female endurance athletes include the interaction between intense training, immune function, and hormonal factors. The menstrual cycle can influence inflammatory responses and recovery patterns [10]. Additionally, the psychological impact of extended training restrictions in competitive athletes requires careful management to prevent deconditioning anxiety and rushed return decisions.

Prognosis and Athlete Counseling

The prognosis for acute perimyocarditis in young, previously healthy athletes is generally excellent, with most experiencing complete recovery within 3-6 months [11]. However, I counsel athletes about potential complications including recurrent episodes (10-15% risk), progression to chronic pericarditis, or rarely, dilated cardiomyopathy.
Predictors of prolonged recovery include elevated troponin levels >20ng/L, extensive myocardial involvement on cardiac MRI, and concurrent arrhythmias. In this case, the presence of epicardial late gadolinium enhancement suggests more significant myocardial involvement, potentially extending recovery time to 4-6 months.
Shared decision-making is paramount. I discuss the timeline realistically: achieving clearance for the world championships in six months is possible but depends on individual recovery patterns. I emphasize that premature return carries risks of arrhythmias, sudden cardiac death, and chronic cardiac dysfunction. The conversation includes exploring alternative competitive goals if recovery extends beyond the championship timeline.
I recommend genetic counseling if there’s suspicion of underlying cardiomyopathy, and discuss long-term monitoring strategies including annual cardiac assessments for competitive athletes.

Take-Home Messages

• Early recognition is crucial: Post-viral cardiac symptoms in athletes warrant immediate cardiac evaluation and training cessation until inflammatory cardiac disease is excluded.
• Comprehensive diagnostic approach: Combine clinical assessment, biomarkers, ECG, echocardiography, and cardiac MRI for accurate diagnosis and risk stratification in suspected perimyocarditis.
• Mandatory rest period: Complete exercise restriction during acute inflammatory phase prevents complications and facilitates recovery—there are no shortcuts in inflammatory cardiac conditions.
• Graduated return protocol: Follow evidence-based, stepwise progression over 3-6 months with careful monitoring at each phase before competition clearance.
• Multidisciplinary management: Involve cardiologists, exercise physiologists, and sports psychologists to optimize both cardiac recovery and athlete wellbeing during extended restrictions.
• Realistic timeline counseling: Major competitions within six months may be achievable but require individualized assessment—prioritize long-term cardiac health over short-term competitive goals.

Image credits: Openart.ai (2025).
Model: Seedream 4.0. http://www.openart.ai
Prompt: “Educational medical illustration of a 23-year-old female elite distance runner in modern running attire (singlet, shorts, running shoes). She is shown standing and slightly holding her chest with a pained expression. A transparent anatomical overlay reveals the heart inside her chest. The heart is drawn in a stylized, textbook-like medical diagram style: the myocardium highlighted in reddish tones to indicate inflammation, and the pericardial sac depicted with a subtle glowing halo to show pericarditis. Neutral light background, clean and professional style, no labels, 4k resolution.”

References

1. 1. Drazner MH, Bozkurt B, Cooper LT, et al. 2024 ACC expert consensus decision pathway on strategies and criteria for the diagnosis and management of myocarditis: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025;85:391-431.
2. Wilson MG, Hull JH, Rogers J, et al. Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians. Br J Sports Med. 2020;54(19):1157-1161.
3. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964.
4. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities. J Am Coll Cardiol. 2015;66(21):2343-2349.
5. Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis. Eur Heart J. 2013;34(33):2636-2648.
6. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.
7. Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015;314(14):1498-1506.
8. Pelliccia A, Solberg EE, Papadakis M, et al. Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis. Eur Heart J. 2019;40(1):19-33.
9. Baggish AL, Drezner JA, Kim J, et al. Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes. Br J Sports Med. 2020;54(19):1130-1131.
10. La Gerche A, Heidbuchel H. Can intensive exercise harm the heart? You can get too much of a good thing. Circulation. 2014;130(12):992-1002.
11. Hackney AC, Lane AR. Exercise and the regulation of endocrine hormones. Prog Mol Biol Transl Sci. 2015;135:293-311.
12. Imazio M, Trinchero R. Myopericarditis: Etiology, management, and prognosis. Int J Cardiol. 2008;127(1):17-26.

The expert’s review

PD Dr. med. David Niederseer

The first section of the AI generated text is very well written, and I have nothing to add. My recommendation differs from the AI generated text beginning with the management of this athlete.
First, colchicine should be given in a reduced dosage of 0.5mg once daily if the athlete weights <70kg. I did not report the exact weight of this athlete in my case vignette, however, we can assume that this athlete weighs less than 70kg based on the description of this case. Secondly, I usually give ibuprofen 600mg three times a day at the beginning of the treatment but taper to twice daily and then once daily, depending on the symptoms. While colchicine has been shown to actually affect the course of perimyocarditis, NSAIDs have not, and are entirely used to relief symptoms. I would also add a proton-pump inhibitor in addition to NSAIDs in this patient.
The subacute phase description is very vague. Athletes need numbers and clear directions about what to do and what they should avoid. I typically tell athletes with perimyocarditis to avoid any sweating or shortness of breath during exercise even outside of sporting activities. Furthermore, I recommend an upper limit of heart rate also at this stage, with 60% of maximal heart rate as a rule of thumb, with individual variations depending on the athlete. Also, during this stage, a physiotherapist could work on leg axis or running specific strength with the athlete, if tolerated. It is crucial, however, to not stress the cardiopulmonary system at this stage of the healing process.
After isolated pericarditis, return to play might start after just one month, many athletes with perimyocarditis or myocarditis might take 3-6 months to completely resolve with symptoms, inflammatory and cardiac markers, and normal cardiac function. What is very important is mentioned by the AI only for elite athletes: cardiac MRI. I perform, based on the current guidelines, cardiac MRI in most athletes with suspected (peri-)myocarditis, also in recreational athletes. Late gadolinium enhancement (hinting fibrosis) and T2-weighted imaging (hinting edema) are important components to individualize the return to play schedule in athletes.
I have checked the references. Reference 4 was cited incorrectly; the other citations were correct. However, some of the references referred to outdated publications, e.g. Ref 3 refers to the 2015 ESC guidelines on pericardial diseases, omitting the 2025 ESC guidelines on myocarditis and pericarditis.
In summary, I think that AI can have a role in helping physicians to treat their patient-athletes. Especially the first part on general aspects is, I think, helpful. But, as pointed out above, I think that AI will not replace a good sports and exercise medicine doctor in the next years. AI would have used a wrong dosage of colchicine in this runner, very likely causing harm. And also, the return-to-play plan is not individualized and detailed enough to be ready for use in ­patient-athletes.

Author profile

PD Dr. med. David Niederseer
david.niederseer@hgk.ch



Affiliation: Hochgebirgsklinik Davos, Medicine Campus Davos
Specializations: Cardiology, Sports Medicine, Sports Science
Year of my medical school graduation: 2008
Sports organizations/federations I work with: Swiss Ski
Fields/topics I am fond of: Sports Cardiology, Cardiopulmonary Exercise Testing, Cardiac Rehabilitation
Outside of Sports & Exercise Medicine, I also love: Sports, Family, Mountains
How I use AI: for work and also privately, to make life ­easier