In part four of the Long COVID series, TeamHealth’s Emerging Infectious Disease Taskforce (EIDT) addresses the major cardiovascular issues reported. Despite the recent development of Long COVID, researchers are gaining a better perspective on related cardiovascular problems.
COVID-19 and the Cardiovascular System
Cardiovascular complications have been well-known since the onset of the pandemic. The EIDT covered the likely pathophysiology in the first segment of this series. Now, recent studies support that the risk and prevalence of cardiovascular disease due to COVID-19 beyond 30 days and to the one-year mark are high. This risk increases as higher levels of care are needed. Notably, there is a substantial risk one year post-COVID-19 for cardiovascular risk and disease in people versus those uninfected.
Classification of Long COVID Cardiovascular Problems
COVID-19 can result in almost any cardiovascular-related problem. The most commonly reported are:
- Myocardial Infarction and Myocardial Injury
- Thromboembolic Disease
- Ventricular Dysfunction and Heart Failure
- Cardiac Inflammatory Diseases – Pericarditis/Myocarditis
- Cerebrovascular Disease
Dysrhythmias represent the most common cardiovascular Long COVID abnormality. Patients have demonstrated an increased prevalence after suffering mild through severe COVID-19. This is particularly true of patients admitted to the critical care setting.
- Atrial fibrillation is the most commonly reported and can negatively impact outcomes, though the severity and persistence are currently unclear. While dysrhythmias are common during many acute illnesses, new instances have been reported in up to 33% of mild COVID-19 cases.
- Episodes of Postural Orthostatic Tachycardia Syndrome (POTS) have likewise been reported. POTS may persist for months or years following infection. In addition, rare cases may have a weak association with COVID-19 mRNA vaccinations; however, the incidence is consistent with other vaccinations and is very small.
- QT-interval prolongation increases the risk of patients progressing to polymorphic ventricular tachycardia. QT prolongation also develops in many patients with mild disease. This raised concerns during the early pandemic when unstudied or unsupported treatments such as chloroquine, hydroxychloroquine and azithromycin were often indiscriminately used.
Myocardial Infarction and Injury
Cardiac Injury was a noted factor in acute COVID-19 early in the pandemic. It has been reported that increasingly higher troponin levels correlate with increasingly higher mortality in acute COVID-19 patients. How this translates to Long COVID complications is not yet clear. No strong clinical signal has been detected.
Ventricular Dysfunction and Heart Failure
Long COVID cases studied show substantial heart failure and cardiac arrest risk. In addition, the risk of post-COVID-19 patients progressing to cardiogenic shock during an acute cardiac event is quite high. Follow-up studies indicate that both right and left ventricular dysfunction may persist in patients suffering acute coronary syndromes during acute COVID-19.
Cardiac Inflammatory Diseases – Pericarditis/Myocarditis
Cardiac dysfunction after mild cases using functional cardiac MRI studies rather than direct clinical data has been reported at alarmingly high prevalence. Fortunately, the actual impacts, although still significant, may not be as dramatic as initially feared. Evidence shows ongoing myocarditis/pericarditis develops in a higher proportion of post-COVID-19 patients than in the uninfected population; however, some studies have indicated a relatively small population effect.
Despite some good news, the risks of inflammatory disease are concerning. Current Long COVID cardiovascular studies mostly reach out to a year post-recovery, but inflammatory processes can take much longer to manifest. This suggests a need for enhanced monitoring and a higher index of suspicion for post-COVID-19 patients.
Reports of enhanced thromboembolic disease began appearing early in the pandemic and risk remains at a significant level for Long COVID patients. This is likely one of the more concerning cardiovascular phenomena associated with COVID-19 and Long COVID. This is not only due to the disability and potential mortality represented, but also because there are reasonable diagnostic tests, treatments and more importantly, preventive management.
Neurologic complications of Long COVID have been previously covered in this series. Given the demonstrated increased risk of transient ischemic attacks (TIA) and stroke, post-COVID-19 patients are at a potential 1.5 times greater risk for cerebrovascular events. Although the management of these events is consistent regardless of cause, a higher index of suspicion should be maintained.
Delayed Care and Disruption of Medical Infrastructure Dynamics
It is also important to note that delays in seeking acute or continuing cardiac care due to the pandemic over the last several years have had substantial impacts. These delays in care have often resulted in more adverse outcomes of greater severity. The adverse outcomes translate to a higher prevalence of long-term cardiac problems. The pressures of the pandemic have also led to a widening of healthcare disparities along ethnic and socioeconomic strata.
Cardiovascular Impacts of Long COVID
The existing and growing numbers of studies show strikingly elevated levels of risk for cardiovascular complications months to years following recovery. Based on these problems alone, COVID-19 is expected to elevate the prevalence many other long-term conditions, including stroke-related syndromes, hypertension and more. Although there is more information regarding individuals with severe COVID-19, those with mild or even asymptomatic COVID-19 do share in some of the elevated risks. Long-term studies are still in progress.