NBPA Cardiologist Opens Up About League’s COVID-19 Concerns

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Dr. Matthew Martinez has been a cardiologist for the NBA player’s association for nearly two years. It’s an important role that’s intensified during the pandemic. COVID-19’s threat to the heart can be serious, and, to assist those who tested positive, Martinez helped establish safety protocols for every player in the NBA. He’s a resource on call whenever they need him.

As a noninvasive cardiologist for New Jersey’s Atlantic Health System at Morristown Medical Center, Martinez also works with Major League Soccer, the Pac-12 and several similar institutions. This week, along with others in his field, Martinez plans to submit a paper he cowrote to JAMA Cardiology—a monthly peer-reviewed medical journal that’s published by the American Medical Association—that reveals new data about the heart-related effects COVID-19 has had on professional athletes across multiple leagues, including the NBA.

On Tuesday afternoon, Sports Illustrated spoke with Martinez about his new paper, what concerns he still has about COVID-19, the No. 1 question NBA players still ask him and more.

This interview has been edited for length and clarity.

Sports Illustrated: Do we know anything new about how COVID-19 attacks the heart that we didn’t know over the summer and in the early fall, during the NBA bubble?

Dr. Matthew Martinez: We do. Initially our concern was based primarily on hospitalized, sicker patients with COVID-19, and we were concerned about its effect on the athlete heart, given the potential for myocarditis—or damage to the heart muscle—being a cause of sudden death in athletes. And what we now know is that the prevalence of cardiac involvement among athletes, specifically professional athletes and specifically the NBA players, is unusual. It’s rare.

And you’re gonna see that data very soon. We hope to be submitting it by the end of the week. The paper is written. I’m going to dance around exactly what it showed intentionally, but from all the professional leagues that we collaborated [with] in really an unprecedented fashion, what we found is the amount of myocardial involvement was much lower than expected, and really not a whole lot different from what you might expect for viruses in general.

What we have is a protocol that was very successful and kept the players’ best interest in mind. It was conservative. It evaluated the athletes in a more conservative fashion than many other entities around the U.S. The reasons why may certainly be due to resources. The professional teams have more resources than a local high school would.

But it taught us a lot about who needs to be evaluated. And what we found in general was we’re not seeing a lot of cardiac involvement amongst asymptomatic or mild cases of COVID-19. We were also better able to identify what separates a mild case from a moderate case and a severe case, which is pretty straightforward. If you’ve got low oxygen levels and you require a hospital stay, then you’re a severe case.

If you’re a mild case, we now define this as symptoms above the neck, so loss of taste or smell, headache, those would be considered above-the-neck symptoms and mild. Moderate symptoms we describe as fevers, chills, if you’re breathless, if you have chest pressure, you fall in that moderate group.

SI: What else can you tell us about the paper?

Martinez: There are lots of contributors from the NFL, MLS, NHL. Dr. David Engel, who is the NBA cardiologist, is the other primary author on this. It will be submitted to JAMA Cardiology by the end of the week, and obviously I couldn’t tell you if they’ll accept it or not, but we think it’s a really good paper and we think they’ll accept it. We have been talking about this data for so long, it’s coming. I can tell you, it’s a lot. Over 700 players.

SI: Given those findings, has the NBA’s safety protocol process changed at all from what it was during the bubble?

Martinez: If we test you and find SARS-CoV-2, that you’ve been infected by the virus, then we do three tests. One, an electrocardiogram or an EKG. Two, an echocardiogram, which is an ultrasound that looks at the heart muscle itself. And the third is a blood test known as troponin. And that has not changed from the bubble until now.

Even though we know that we’re going to find nothing in the vast majority in that asymptomatic and mild group, we still feel like it’s a little early to be not performing those tests on this group of elite athletes, entirely because we want to make sure the player is safe. We know after the bubble that we haven’t had any significant or bad outcome, and we’re probably not going to identify any new findings, but until we have better data—six months, a year, two years from now—we want to make sure the athletes are safe.

So what we don’t know is that just because you had no findings after a few weeks, in the follow-up study—preseason testing like we always do—are we gonna find something that we didn’t expect. We don’t expect it but they’re elite athletes, and they fall into a different category. And quite frankly there’s some level of expectation, to sort it out both for the professional athletes as well as the remaining athletes around the country who want to know are they at risk and what the risks are. There’s a duty involved in that, and I think we feel that.

SI: Despite your findings regarding myocarditis, is it still the primary cause of concern? And what would the effect be, do you think, among other players or even the NBA as a league, if someone was diagnosed with it?

Martinez: We’re looking for myocardial injury, myocarditis, meaning a virus attacks the muscle or an inflammation from the virus itself that causes damage to the muscle. We’re looking for pericardial damage, so damage to the sack around the outside of the heart, and then any changes in the pressure in the lungs that we can identify inside the heart. And we can do that with the screening study that we talked about.

It’s hard to know what a player would think if somebody was found with that. I wouldn’t want to speculate other than saying I would want to know, if something was found, that I was being screened appropriately to make sure if I had this [too]. The best we can do is say we’re gonna work together to identify anyone who’s at risk. We’re gonna be vigilant to make sure that in the event that you have a finding, that we identify it and that we do our best to follow up with that and be on top of it.

I’ve spoken with more athletes who’ve had viral illness in the last six months to a year than I had in the previous decade. So to say that we’re being diligent in this group would be the understatement of the [year].

SI: Beyond myocarditis, what are some other possible COVID-19-related conditions you check for and that players might be impacted by?

Martinez: So when we think of COVID-19 in the heart, we’re thinking of the muscle disease, the sack around the heart. We know that in hospitalized patients, in non-athletes, we’re seeing clots and thrombosis related to COVID-19. It creates an increased risk for clotting. We know that NBA players clot. But we have not seen an increased signal in the NBA or really any of the professional sports that we’ve seen.

And then the other [question] is how is it affecting the lungs? Are we seeing lung damage or increased pressure inside the lungs related to COVID-19 from scarring and damage to the lungs themselves? We have not seen that in any of the athletes we’re screening, but it’s certainly a concern.

SI: With games back, players no longer inside a bubble, and the pandemic still raging as strong as it ever has, what do you worry the most about, for NBA players?

MM: So far the safety data is reassuring, and I think I’m less concerned now than I was a year ago. I feel very comfortable with the protocol we have in place. I think we’re at a much better place than we were before because we learned a lot in the last six months to a year. And I’m not sure that I have any specific concerns at this point. I’m very proud of the protocol, I think it’s worked very well. And I think that the players should be very satisfied that we’re evaluating them in completeness.

I’ve spoken with more professional NBA players as well over the last six months, who have my cellphone number. So even if things are normal, and they say, “I really want to talk to a cardiologist. I just need to feel better about it,” they have that. They have me and they have their team cardiologist. All access really within a day or so. Sometimes it’s their significant other who says, “Listen, I know you think you’re bulletproof, but I want to hear it. I want to talk to him.” And I think the players have that, and they have that like never before.

SI: What is the most common question asked when you talk to players?

MM: The most common question is “How am I going to do long-term? Is this going to affect my ability to play?” And so far the answer to that has been we don’t think so. If you have any damage to the heart muscle, we’re gonna put you on a pause and there’s no reason to think that this is gonna have some long-term sequelae of the heart. And I think they need to hear that.

SI: Should an NBA player suffer from myocarditis after testing positive for COVID-19, what would their treatment plan be?

MM: There are ways to manage it. There’s no specific therapy for it, but if a player had myocarditis, we would put them on a pause. We would hold athletics for the next several months, rest that heart muscle and then reinvestigate it in two to three months. If all things return to normal, then they would start to exercise. At that stage, the vast majority, well over 99%, are going to recover and do really well.

SI: What was your reaction to Keyontae Johnson’s collapsing on the court during a game last month? He had COVID-19 and passed a complete cardiac evaluation after recovering from it. But he still reportedly had myocarditis.

MM: My reaction was I need to know more of the data. I want to know more about when he was infected, because that’s a pretty big separation between August, September and a December event. So I’m not sure. The University of Florida has baseline data on all of their athletes that they can compare to existing data, so if they tell me it’s normal, then it’s normal. And that’s what I heard, that it was normal after his evaluation. What I don’t know is: Did something else occur when he had this event in December?

I’ve been saying this from the beginning, and I’ll say it again. I said it to the American College of Sports Medicine and I’ve said it in every talk I’ve given on this condition: We’re never gonna have a perfect screening protocol. It’s never gonna happen. There’s always gonna be something that’s COVID-related, or not.

Because you can have other viral illnesses, you can have some other problem we didn’t recognize. I don’t know if Keyontae falls in that category or not, but an emergency action plan, a defibrillator, and a well-trained medical staff, which thankfully the University of Florida has, will lead to the outcome that you saw. He did really well, it seems.

SI: Were NBA players frantic after that event?

MM: Some. I was inundated with questions. “Do you know anything about this guy? What happened? Did he have it? Did he not have it?” All of which are the same answers I’m giving you. I don’t know Keyontae. I have not seen any images from him. I don’t know anything about his medical history and whether or not he had any preexisting conditions. I don’t know.

I know there are myriad reasons why folks have the event that he had, and the separation from his COVID-positive test suggests to me that the relationship to COVID is still unclear.

SI: Players who test positive for COVID-19 are supposed to have follow-up tests on their heart to rule out or discover any irregularities. How frequent are those?

MM: It would depend on when you tested positive, but [follow-ups] are in that three-to-six-month range, and to my knowledge there’s no one who had a follow-up test who’s had a new finding compared to the prior [test]. For the NBA it’s an annual echocardiogram, electrocardiogram and stress echo. Every single year [before the season]. For all the players.

SI: How do you approach players who’ve tested positive for COVID-19 multiple times?

MM: None of that changes from our standpoint. Is it overkill? It might be, but if the resources are available then it’s reasonable to do that. Not knowing enough about the COVID test that they tested positive for, I have to sidestep that a little bit, only because what I don’t know is did they test positive for IGG six months ago, meaning that they had an antibody test, and now they tested positive for PCR? Is that a false-positive test? How soon can you repeat the test? I know now having been fully vaccinated, I’m not allowed to get a PCR test for at least another three months, because it’s gonna test positive. That’s what I’m told.

SI: And every player has had their heart tested?

MM: To my knowledge, everyone went through the standard NBA preseason protocol, and there were no new unexpected findings identified.