Q&A outlines cardiac implications of COVID-19

Author: Ty Gluckman, M.D., MHA, FACC, FAHA, FASPC, medical director, Center for Cardiovascular Analytics, Research + Data Science, Providence Heart Institute

What research is CARDS doing on the heart-related consequences of COVID? 
Much of our research at CARDS – the Providence Center for Cardiovascular Analytics, Research + Data Science – seeks to better understand how health care patterns changed during the pandemic. This includes:

  • Evaluating rates of hospitalization for myocardial infarction early in the pandemic
  • Determining how rates of infection in the community have affected in-hospital mortality rates
  • Developing best practices for evaluating and treating myocarditis and long COVID

How is the heart affected by COVID-19?
Various forms of cardiovascular disease have been reported with COVID. During the acute phase, arrhythmia, myocardial ischemia, heart failure and thromboembolism can occur, with both viral- and host-mediated responses playing a role. Viral myocarditis has received significant attention, with greatest risk faced by those with concomitant pneumonia. Triad testing with a 12-lead ECG, cardiac troponin and echocardiogram is recommended in those with an increased suspicion for cardiac involvement.

Has there been an increase in cardiac patients since the onset of the pandemic?
Very early in the pandemic, significantly fewer cardiac patients were seen in our clinics and hospitals. This most likely was the result of patients staying at home out of fear of getting infected with COVID. Over the last two years, however, the number of cardiac patients being seen has largely returned to pre-pandemic levels. 

Can people with mild or asymptomatic COVID still experience heart issues?
While some types of cardiac disease are found more often with severe COVID, long COVID can follow mild and even asymptomatic infection. 

What cardiac symptoms are associated with long COVID?
Long COVID consists of a constellation of new, returning or persistent health problems experienced by individuals four or more weeks after SARS-CoV-2 infection. It is estimated to affect 10-30% of patients with COVID-19.

Individuals with long COVID commonly experience wide-ranging symptoms, including fatigue, exercise intolerance, sleep disturbance and memory problems. Chest pain, shortness of breath and palpitations represent some of the key symptoms that draw attention to the cardiovascular system. Given that the pathophysiology of long COVID is poorly understood and the underlying drivers may be heterogeneous, a unifying explanation often is lacking.

What are some of the complexities of cardiac diagnosis with COVID?
Several known cardiovascular disease entities (e.g., myocarditis, arrhythmia and heart failure) can present during the early post-acute and chronic periods of COVID-19. Discerning whether these conditions began with acute infection, during illness resolution, or as a new condition post-recovery can be challenging. This may, in part, be related to variability in the timing of clinical presentation and the type of diagnostic testing performed. Self-isolation may further limit early detection; moreover, some patients may choose to defer care, with the expectation that any lingering symptoms will improve over time. Where possible, evaluation and management of these conditions should follow existing guideline recommendations.

For some patients, cardiovascular symptoms may not be fully explained by initial testing.  Exercise intolerance and palpitations are two of the most common reported symptoms; others include chest pain and dyspnea. These patients may meet criteria for other conditions, including postural orthostatic tachycardia syndrome (POTS) and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Because multiple mechanistic underpinnings may play a role, rather than focusing on a specific mechanism, which may be a challenge to identify and address, it generally is recommended that treatments be identified that target the most prominent cardiovascular symptoms.

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