Long-term cardiac surveillance and outcomes of COVID-19 patients

Abstract

Acute cardiac manifestions of COVID-19 have been well described, while chronic cardiac sequelae remain less clear. Various studies have shown conflicting data on the prevalence of new or worsening cardiovascular disease, myocarditis or cardiac dysrhythmias among patients recovered from COVID-19. Data are emerging that show that patients recovering from COVID-19 have an increased incidence of myocarditis and arrhythmias after recovery from COVID-19 compared with the control groups without COVID-19. The incidence of myocarditis after COVID-19 infection is low but is still significantly greater than the incidence of myocarditis from a COVID-19 vaccine. There have been several studies of athletes who underwent a variety of screening protocols prior to being cleared to return to exercise and competition. The data show possible, probable or definite myocarditis or cardiac injury among 0.4-3.0% of the athletes studied. Recent consensus statements suggest that athletes with full recovery and absence of cardiopulmonary symptoms may return to exercise and competition without cardiovascular testing. In conclusion, patients with COVID-19 may be expected to have an increased risk of cardiovascular disease, myocarditis or arrhythmias during the convalescent phase. Fortunately, the majority of patients, including athletes may return to their normal activity after recovery from COVID 19, in the absence of persisting cardiovascular symptoms.

Fig. 1

Observational data from VA database showed increase in cardiovascular, and dysrhythmic disorders in veterans with COVID-19 compared with matched Veterans without COVID-19. Risks and excess burdens were assessed at 12 months stratified by acuity of initial COVID-19 infection: non-hospitalized (green), hospitalized but not in intensive care for COVID-19 (orange) and admitted to intensive care (blue). Within the COVID-19 cohort, non-hospitalized (n = 131,612), hospitalized (n = 16,760), admitted to intensive care (n = 5388) were compared with contemporary control cohort (n = 5,637,647). Adjusted HRs and 95% CIs are presented. The length of the bar represents the excess burden per 1000 persons at 12 months.

Fig 2

This ECG is from a 35 year old woman who had a mild course of COVID 19 six weeks prior to presentation with syncope and incessant ventricular tachycardia. Subsequent CMR evaluation showed elevation elevation in T1 and T2 with delayed enhancement in a nonischemic pattern consistent with myocarditis. The patient was treated with steroids, beta blockers and amiodarone. CMR-cardiac MRI

Fig. 3

Most patients recovered from COVID 19 will be asymptomatic or will not have cardiopulmonary symptoms. For these athletes, clinical testing is not required. For athletes with persisting cardiopulmonary symptoms, we recommend clinical evaluation with triad of testing (biomarkers, ECG, and echocardiogram with consideration for exercise treadmill test). For athletes who were hospitalized with COVID-19, a period of convalescence followed by cardiac testing, depending on presence of cardiopulmonary symptoms may be required before allowing the patient to return to exercise and competition.