Physician Group Releases Guidance on Cardiovascular Issues in Long COVID

Risks for cardiovascular complications, including pulmonary embolism, arterial and venous thromboses, myocardial infarction, and stroke, are higher in patients with post-acute sequelae of SARS-CoV-2 (PASC), or long COVID, highlighting the need for greater awareness of these conditions among clinicians, according to a consensus statement released by the American Academy of Physical Medicine & Rehabilitation (AAPM&R).

Cardiovascular complications may arise weeks or months after a patient's initial COVID-19 infection, with severity of the symptoms ranging from "mild to incapacitating," according to the PASC Collaborative, a multidisciplinary group of physicians, clinicians, and patient advocates, who developed the statement. They noted that 5% to 29% of COVID-19 survivors complain of cardiovascular symptoms such as chest pain, dyspnea, or palpitations months after their recovery from the acute infection.

"Unfortunately, many people could have chronic cardiovascular conditions due to COVID-19 infection -- even patients without previous cardiovascular disease, comorbidities, and otherwise low risk of cardiovascular disease," said ​​lead author Jonathan Whiteson, MD, of NYU Langone Health in New York City, in a press release. "Because of the chronic nature of cardiovascular conditions, there will likely be long-lasting consequences for patients and health systems worldwide."

Whiteson and colleagues noted that the new consensus statement, the fourth in a series of guidance statements released by AAPM&R, was created to help improve awareness and understanding about this new and widespread condition. The PASC Collaborative was designed to share the best collective knowledge from across medical fields in one place for providers who are tasked with identifying long COVID and its many manifestations.

The goal of the consensus statement was to help providers address patient needs in whatever specialty they are practicing, explained co-author Alba Azola, MD, co-director of the Post-Acute COVID-19 Team at Johns Hopkins Medicine in Baltimore.

"We are not enough," Azola told MedPage Today. "In terms of the post-COVID clinics, there's just not enough for the millions and millions of Americans that are affected."

The guidance, in a nutshell, recommends that physicians become more vigilant about the potential for cardiovascular disease caused by long COVID, especially in patients with no history of cardiovascular complications, calling for targeted education of both healthcare professionals and patients with long COVID.

Whiteson and team advised that all stakeholders learn about the heterogeneity of long COVID symptoms, the likelihood of developing long COVID, the difference between expected symptoms and clinical red flags, lifestyle changes to help ease symptoms, and the connection between the cardiovascular and nervous systems.

This will help both physicians and patients identify the risk factors for cardiovascular complications related to long COVID, they said. Specifically, they noted that patients may experience shortness of breath, fatigue, chest pain, palpitations, dizziness, abdominal bloating, leg swelling, and reduced tolerance for exercise or activity.

To help physicians diagnose and treat patients with long COVID who may present with these symptoms, Whiteson and team outlined several best practices. First, they recommended that a full patient history be taken, including details about any previous COVID-19 infections, such as severity of initial infection and need for ventilator or extra-corporeal membrane oxygenation. Physicians should also note any common or worsening cardiac complaints. In addition, the authors recommended the use of all relevant testing, such as electrocardiograms, echocardiograms, cardiac stress tests, and standard lab tests.

The authors stressed that physicians should focus on modification strategies for risk factors, including hypertension, diabetes, obesity, tobacco use, and sedentary behavior. These modifiable risk factors are associated with greater morbidity and mortality in patients with COVID-19. New research is attempting to define their effects in patients with long COVID.

If patients are experiencing severe cardiovascular complications or disorders, such as arrhythmias, coronary artery disease, or ventricular dysfunction, the next recommended step would be to refer them to the appropriate specialist or a cardiac or long COVID rehabilitation center, the guidance states.

"I think the future will entail a state where we are talking about COVID as a risk factor," Whiteson said. "If someone has had COVID, they may develop cardiovascular disease even in the absence of other risk factors, so look carefully and interpret symptoms cautiously because it's not something you want to miss."

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