Management of Post-COVID Cardiac Symptoms

Neil Skolnik, MD; Susan K. Fidler, MD


May 20, 2022

This transcript has been edited for clarity.

Neil Skolnik, MD: I'm Dr Neil Skolnik, and today we're going to talk about the American College of Cardiology's expert consensus statement on cardiovascular sequelae of COVID-19. Joining us today is Dr Sue Fidler, who is a family physician and a sports medicine specialist.

Susan K. Fidler, MD: Thanks, Neil.

Skolnik: This statement is important because about 30% of patients after COVID-19 have prolonged symptoms, often called "long-haul COVID" or post-acute sequelae of COVID. Cardiovascular symptoms are common. They include chest pain, shortness of breath, lightheadedness, and palpitations and they're a real challenge for us. The statement is helpful. It says get some labs: a complete blood cell count (CBC), a basic metabolic panel, and a troponin and a C-reactive protein level.

If the patient is having cardiovascular symptoms, then get an EKG and an echocardiogram. If they're having palpitations, do ambulatory rhythm monitoring. I prefer using an Apple Watch or a KardiaMobile EKG monitor rather than a Holter monitor because we can use it longer-term and get the information when a patient is having symptoms. If the patient is having shortness of breath, then do chest imaging — consider chest radiography or chest CT, and maybe pulmonary function tests. Consider a 10-minute stand test if the patients is having lightheadedness to look for postural orthostatic tachycardia syndrome (POTS). To test for POTS, have the patient stand for 10 minutes after being seated. An increase in pulse rate of 30 beats/min or a heart rate of 120 beats/min with symptoms means they have POTS. If the patient is having chest pain, you would have a lower threshold than usual for getting a stress test.

If any of the test results are positive, then refer the patient to a cardiologist to determine whether they have myocarditis. Most of the time, our testing is negative and we're left with figuring out how to manage the patient's symptoms.

Fidler: You hit the nail on the head. We're looking at how to manage their symptoms. One important aspect is exercise intolerance — how we talk to someone about getting back into exercise.

Skolnik: Can you go over your approach?

Fidler: When a patient has exercise intolerance, orthostasis, or tachycardia, recumbent exercises are much better for them than standing exercises. What are recumbent exercises? Recumbent bikes, swimming, rowing — these are better tolerated. They should start small — 5-10 minutes at a time at a pace that allows them to be conversational, and then incrementally increase very slowly. They may be only adding 2 minutes per day. Go slow and build up their tolerance. We also want to think about their salt and water intake, and consider support stockings.

Medication-wise, we're managing symptoms. If the patient is having tachycardia, try beta-blockers or calcium-channel blockers. If the patient has orthostasis, then we can try midodrine or fludrocortisone — drugs we've used for similar symptoms for a long time.

Skolnik: That is so helpful. Let's move on now to return to play, which is a common question. We're asked in the office is to give advice or sign off on someone returning to exercise or returning to play after COVID. What are the current recommendations?

Fidler: We knew that myocarditis was a concern, especially among the patients hospitalized with COVID who were really sick, with many cardiovascular complications. But the initial studies were not great at giving us a true incidence of myocarditis. The numbers were all over the board, from a half percent to upwards of 15%. We also noticed that the more testing we did, the more myocarditis we found, but it wasn't always clinically correlated with how the patient was feeling. Everyone got testing whether they had symptoms or not, and over time we realized that symptoms should dictate whether someone has testing.

Skolnik: So what are the current recommendations?

Fidler: The current recommendations are a little easier to digest. The first thing you look at is whether the patient has COVID symptoms or an asymptomatic infection. If the latter, the patient should wait 3 days before returning to play to make sure that symptoms don't develop.

For patients who have mild or moderate COVID that has completely resolved —they have no symptoms such as chest pain, trouble breathing, or palpitations — and are feeling great, we can give them a "graded return to play," which means they are going to slowly return to play over about 7 days and pay attention to how they are feeling. They should start slow, with 15-20 minutes of very light exercise and no lifting. They should extend their exercise a little each day, and by day 4 or 5, they are close to their regular level of activity; by day 6, they should be able to get through a normal workout. The entire time, however, they should pay attention to whether they have any symptoms.

Patients with COVID severe enough to be hospitalized, and those who had COVID but were unable to fully recover and continue to have cardiovascular symptoms, will need an evaluation. As primary care physicians, we manage these patients in consultation with our cardiology colleagues.

We start with the typical triad testing: EKG, echocardiography, and a highly sensitive troponin level. If all of those tests are normal, those folks can consider going through their return-to-play progression, and if necessary, the measures we discussed for exercise intolerance. If any of the triad testing results are positive, or the patient has myocarditis, refer the patient to a cardiologist for further evaluation (cardiac MRI, long-term ambulatory rhythm monitoring). Furthermore, they should avoid strenuous physical activity for 3-6 months.

In summary, if they have no symptoms, get them slowly back into play. If they have symptoms, they need an evaluation and often a consult with a cardiologist.

Skolnik: Sue, that's such helpful, practical advice. Thanks so much for joining us for Medscape.

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