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Review
. 2023 Jun;39(6):741-753.
doi: 10.1016/j.cjca.2023.04.003. Epub 2023 Apr 6.

Cardiovascular Considerations in the Management of People With Suspected Long COVID

Kieran L Quinn  1 , Grace Y Lam  2 , Jillian F Walsh  3 , Anne Bhéreur  4 , Adam D Brown  5 , Chung Wai Chow  6 , Kit Yan Christie Chung  6 , Juthaporn Cowan  7 , Noah Crampton  8 , Simon Décary  9 , Emilia L Falcone  10 , Lorraine Graves  11 , Douglas P Gross  12 , Kate Hanneman  13 , Paula J Harvey  14 , Sheila Holmes  6 , Gabrielle M Katz  15 , Parinaz Parhizgar  16 , Abdu Sharkawy  6 , Karen C Tran  17 , Susan Waserman  18 , Vanessa E Zannella  19 , Angela M Cheung  20
Affiliations
Review

Cardiovascular Considerations in the Management of People With Suspected Long COVID

Kieran L Quinn et al. Can J Cardiol. 2023 Jun.

Abstract
in English, French

Approximately 15% of adult Canadians with SARS-CoV-2 infection develop lingering symptoms beyond 12 weeks after acute infection, known as post-COVID condition or long COVID. Some of the commonly reported long COVID cardiovascular symptoms include fatigue, shortness of breath, chest pain, and palpitations. Suspected long-term cardiovascular complications of SARS-CoV-2 infection might present as a constellation of symptoms that can be challenging for clinicians to diagnose and treat. When assessing patients with these symptoms, clinicians need to keep in mind myalgic encephalomyelitis/chronic fatigue syndrome, postexertional malaise and postexertional symptom exacerbation, dysautonomia with cardiac manifestations such as inappropriate sinus tachycardia, and postural orthostatic tachycardia syndrome, and occasionally mast cell activation syndrome. In this review we summarize the globally evolving evidence around management of cardiac sequelae of long COVID. In addition, we include a Canadian perspective, consisting of a panel of expert opinions from people with lived experience and experienced clinicians across Canada who have been involved in management of long COVID. The objective of this review is to offer some practical guidance to cardiologists and generalist clinicians regarding diagnostic and treatment approaches for adult patients with suspected long COVID who continue to experience unexplained cardiac symptoms.

Environ 15 % des adultes canadiens atteints d’une infection à SRAS-CoV-2 présentent des symptômes qui persistent plus de 12 semaines après la phase aiguë de l’infection, ce qu’on appelle le syndrome post-COVID ou la COVID longue. Certains des symptômes cardiovasculaires courants rapportés dans les cas de COVID longue comprennent la fatigue, l’essoufflement, les douleurs à la poitrine et les palpitations. Les complications cardiovasculaires à long terme présumées de l’infection à SRAS-CoV-2 pourraient se présenter sous la forme d’un ensemble de symptômes difficiles à diagnostiquer et à traiter pour les cliniciens. Lors de l’évaluation des patients présentant ces symptômes, les cliniciens doivent garder en tête l’encéphalomyélite myalgique, ou syndrome de fatigue chronique, le malaise post-effort et l’exacerbation des symptômes post-effort, la dysautonomie avec manifestations cardiaques comme une tachycardie sinusale inappropriée, et le syndrome de tachycardie orthostatique posturale, et parfois le syndrome d’activation mastocytaire. Dans cette synthèse, nous résumons où en sont les données sur la prise en charge des séquelles cardiaques de la COVID longue à l’échelle mondiale. Nous incluons également le point de vue de personnes avec expérience vécue et de cliniciens d’expérience d’un peu partout au Canada qui ont été impliqués dans la gestion de la COVID longue. L’objectif est d’offrir une orientation pratique aux cardiologues et aux généralistes quant aux approches diagnostiques et thérapeutiques à adopter auprès des patients adultes chez qui une COVID longue est suspectée et qui continuent de présenter des symptômes cardiaques inexpliqués.

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Figures

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Graphical abstract
Figure 1
Figure 1
Recommended assessment of long-term cardiovascular and related symptoms among people with previous SARS-CoV-2 infection. This algorithm does not apply to the management of people with cardiovascular complications or abnormal cardiac-related investigations during their acute SARS-CoV-2 illness. CBC, complete blood count; CVD, cardiovascular disease; ECG, electrocardiogram; HbA1c, hemoglobin A1c; ME/CFS, myalgicencephalomyelitis/chronic fatigue syndrome; PESE, postexertional symptom exacerbation; POTS, postural orthostatic tachycardia syndrome; RBG, random blood glucose; RF, risk factors; TSH, thyroid stimulating hormone. a Symptoms include chest pain/pressure, shortness of breath, palpitations, and/or syncope. b Elevated troponin level, ECG changes of diffuse T-wave inversion, ST-segment elevation without reciprocal ST-segment depression, and prolongation of the QRS complex duration and/or echocardiographic wall motion abnormalities (often in a noncoronary distribution, which might also include abnormal ventricular strain).
Figure 2
Figure 2
Recommended treatment of long-term cardiovascular and related symptoms among people with previous SARS-CoV-2 infection. CVD, cardiovascular disease; IST, inappropriate sinus tachycardia; MCAS, mast cell activation syndrome; PESE, postexertional symptom exacerbation; POTS, postural orthostatic tachycardia syndrome.
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