Long COVID symptoms – Is ongoing cardiac damage the culprit?

Residual symptoms after COVID-19 are of global interest. Prolonged cardiopulmonary alterations are common past 4 weeks after infection; however, patients’ complaints do not always match objective findings [1].

“The National Institute for Health and Care Excellence in the United Kingdom has defined long COVID as a persistence of symptoms beyond 4 weeks and has subdivided this into 2 categories: the ‘ongoing symptomatic phase,’ which refers to symptoms up to 12 weeks and the ‘post-COVID-19 syndrome,’ which refers to symptoms that persist beyond 12 weeks,” stated Dr Betty Raman (John Radcliffe Hospital, University of Oxford, UK) [1]. There is a vast multiplicity of patient-reported COVID-19 symptoms beyond 4 weeks, among which fatigue is most common [2–4]. Other widespread symptoms include shortness of breath, headaches, brain fog, and cardiopulmonary symptoms such as chest pain or palpitations. A poorly understood but not rare syndrome in long COVID is postural orthostatic tachycardia. Long COVID patients not only experience a marked reduction in quality of life, but a substantial part is also not able to return to work and normal exercise [1].

Results from a meta-analysis of over 4,000 hospitalised COVID-19 patients, found some sort of myocardial injury in about one-third of patients [5]. An imaging investigation demonstrated, for example, wall motion impairment, right ventricular dysfunction, and pericardial effusion in hospitalised COVID-19 patients [6]. Retrospective cohort studies revealed a 3-fold risk of major adverse cardiac events and a 2 to 3-fold risk of cardiomyopathy in patients after the acute phase of COVID-19 versus a comparator group without COVID-19 [7,8]. There is also prospective data from several smaller cohort studies with hospitalised COVID-19 patients [1]. “All of them do reveal some burden, albeit small, of ongoing cardiac damage in patients being followed up,” Dr Raman explained. Data from cardiopulmonary exercise testing has furthermore found that the main aetiology for reduced exercise tolerance seems to stem from a muscular cause, not cardiopulmonary.

In summary, Dr Raman pointed out that post-acute cardiovascular sequelae are seen for up to 6 months from infection. “However, there does appear to be a dissociation between symptoms experienced by patients and objective abnormalities on cardiopulmonary testing and in the long-term, one must be vigilant of complications of long COVID, in particular the effects of chronic inflammation and endothelial dysfunction, but also the rising epidemic of obesity due to inability of people to become physically active and return to work. This highlights the need for more aggressive risk factor modification in patients recovering from COVID-19,” she concluded.

1. 
   
   1. Raman B. COVID-19 long haulers and cardiovascular risks. Session: Long COVID: does it matter? ESC Congress 2021, 27–30 August.
   2. Ghosn J, et al. Clin Microbiol Infect. 2021;27(7):1041.e1-1041.e4.
   3. Huang C, et al. Lancet. 2021;397:220–232.
   4. Davis HE, et al. EClinicalMedicine 2021;38:101019.
   5. Dy LF, et al. Sci Rep. 2021;11(1):8449.
   6. Giustino G. J Am Coll Cardiol. 2020;76(18):2043–2055.
   7. Ayoubkhani D, et al. BMJ 2021;372:n693.
   8. Daugherty SE, et al. BMJ 2021;373:n1098.

 

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Posted on 26 October 2021