Post-Acute COVID-19 Syndrome and the cardiovascular system: What is known?

Abstract

Post-Acute COVID-19 Syndrome (PACS) is defined by persistent symptoms >3-4 weeks after onset of COVID-19. The mechanism of these persistent symptoms is distinct from acute COVID-19 although not completely understood despite the high incidence of PACS. Cardiovascular symptoms such as chest pain and palpitations commonly occur in PACS, but the underlying cause of symptoms is infrequently known. While autopsy studies have shown that the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) rarely causes direct myocardial injury, several syndromes such as myocarditis, pericarditis, and Postural Orthostatic Tachycardia Syndrome have been implicated in PACS. Additionally, patients hospitalized with acute COVID-19 who display biomarker evidence of myocardial injury may have underlying coronary artery disease revealed by the physiological stress of SARS-CoV-2 infection and may benefit from medical optimization. We review what is known about PACS and the cardiovascular system and propose a framework for evaluation and management of related symptoms.

Keywords: ACE2, angiotensin converting enzyme-2; AF/AFL, atrial fibrillation or flutter; CBT, cognitive behavioral therapy; CFS, Chronic Fatigue Syndrome; CMR, cardiac magnetic resonance imaging; CRP, C-reactive protein; CV, cardiovascular; Cardiology; Coronavirus Disease 2019; ECG, electrocardiography; ECV, extracellular volume; LGE, late gadolinium enhancement; Long COVID; Long-Haul COVID; MCAS, Mast Cell Activation Syndrome; MERS, Middle East Respiratory Syndrome; POTS, Post-Acute COVID-19 Syndrome; SARS-COV-1, Severe Acute Respiratory Syndrome Coronavirus-1; SARS-CoV-2; T1MI, type 1 myocardial infarction; T2MI, type 2 myocardial infarction; TTT, tilt table testing.

Fig. 1

Proposed algorithm for management of COVID-19 recovered patients with persistent cardiovascular symptoms or a previous COVID-19 hospitalization with cardiac complications. ^aPOTS can generally be managed by primary care physicians, but in atypical or refractory cases, referral to a cardiologist or neurologist is advised. Abbreviations: BNP, brain natriuretic-peptide; CAD, coronary artery disease; CMR, cardiac magnetic resonance imaging; CRP, C-reactive protein; ECG, electrocardiogram; ETT, exercise treadmill test; HF, heart failure; MPI, myocardial perfusion imaging; POTS, Postural Orthostatic Tachycardia Syndrome; TTE, transthoracic echocardiogram.