Please Note: The information below is intended for healthcare professionals, specifically primary care providers. These are not meant to be guidelines or supplant individual provider discretion in the management of PASC, as evidence-based consensus guidelines for the diagnosis of management of this new disease do not exist currently. The following represents the expert opinions of an interprofessional group that is appraising emerging evidence and should be interpreted as recommendations and clinical guidance rather than the standard of care.
PASC Cardiac Symptoms: Approach to Dyspnea and Tachycardia
Written May 16, 2021 by: W. Michael Brode, MD, Matthew Seghers, MS3, Faith Noah, MS3, George Rodgers, MD
Hospitalized patients who had severe initial COVID-19 infection have high rates of cardiac injury and should have close evaluation for persistent myocardial injury. On the other hand, patients without a prior cardiac history who did not require hospitalization from mild to moderate COVID-19 have low rates of persistent cardiac abnormalities and will likely not require any advanced testing.
For PASC patients who have dyspnea from a suspected cardiac source (see workup for dyspnea from pulmonary source), obtaining a transthoracic echocardiogram (TTE) with LV strain is a reasonable first step in addition to performing an active stand test or 6-min walk test in clinic to rule out postural syndromes and deconditioning, respectively.
During the acute COVID-19 infection, myocardial injury occurs in up to 36% of hospitalized patients. The exact mechanism of myocardial injury is likely multifactorial, but may include demand ischemia, hypoxic injury, microvascular injury leading to ischemia, myopericarditis from direct viral invasion, or myocardial depression in setting of systemic inflammation (cytokine storm).1
- In another study, 76% of hospitalized COVID-19 patients had elevated troponins during acute illness, with 60% of patients having ongoing myocardial inflammation on cardiac MRI after recovery.2 Diastolic dysfunction, RV strain, and pulmonary hypertension have also been identified.3
Cardiac injury in patients with mild to moderate disease who did not require hospitalization is very rare. In a study of > 3,000 college athlete who recovered from COVID-19, less than 1% had an abnormal troponin, ECG, or echocardiogram. If one of these initial tests was positive, cardiac MRI showed abnormalities in only 13% of patients.4 Similarly, in a study of healthy healthcare workers, cardiovascular abnormalities were no more common in those who recovered from COVID-19 than who were never infected.5
Palpitations, presyncope, and orthostasis are commonly seen in PASC patients. Postural Orthostatic Tachycardia Syndrome (POTS) is previously known to occur after viral or bacterial infections, and is now a widely recognized sequelae of COVID-19, although the prevalence is unclear.6,7
TTE evaluating for LV strain is the best initial diagnostic test for PASC with concern for cardiac involvement. Evaluating for LV strain is the most sensitive test for identifying early systolic dysfunction (same approach used to screen patients prior to starting chemotherapy).
- If normal, a 6-minute walk test (inability to walk 400-600 meters in 6-min is abnormal) to test for deconditioning is recommended. Cardiopulmonary Exercise Testing (CPET) can be obtained if a provider wants a more formal measure of the patient’s functional capacity.
- If abnormal with LV strain or global hypokinesis, referral to cardiology is recommended, they will likely need a cardiac MRI
- If abnormal with regional wall motion abnormality, evaluating coronary artery perfusion with stress testing is recommended
Postural “dizziness” or palpitations should undergo an active stand test in the office (measure supine and standing HR and BP, increase of HR >30 for 30 seconds is indicative of POTS, whereas BP decrease by >20mmHg is indicative of orthostatic hypotension).
If a patient is experiencing frequent palpitations not explained by POTS or orthostatic hypotension above, a baseline ECG followed by 24hr Holter monitor is recommended. If palpitations are infrequent but severe, an external looping event monitor for 5-14 days is recommended.
For PASC patients with decreased ejection fraction on TTE, typical heart failure goal-directed therapy is recommended (ACE-I/ARB, beta-blocker, SGLT-2 inhibitors) in addition to managing comorbidities (HTN, T2DM). Cardiac rehabilitation and repeat TTE in 3 months is also recommended.
For patients who have myopericarditis identified by ECG or cardiac MRI, typical treatment with colchicine and NSAIDs (no corticosteroids) is recommended with cardiology consultation.
POTS is commonly caused by hypovolemia and deconditioning, so an initial trial of volume expansion by drinking 3 liters of fluid per day, increasing dietary sodium, along with physical therapy is recommended.
- POTS can also have a “neuropathic” and “hyperadrenergic” phenotype. If no response to volume expansion and conditioning above, referral to neurology, cardiology, or PMNR is reasonable for further characterization of POTS.
- Neuropathic POTS can be treated with compression stockings or improving peripheral vascular tone with midodrine
- Hyperadrenergic POTS should have good medication reconciliation as SSRIs/SNRIs can exacerbate symptoms. Beta-blockers are the mainstay of treatment for this phenotype but should be monitored closely given their array of side effects.8
Arrhythmias identified on Holter monitoring should be referred to cardiology for evaluation, unless it is typical atrial fibrillation and the primary care provider can manage independently (i.e., risk stratification, rate/rhythm control, and stroke prevention).
1. Lala, A. et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J. Am. Coll. Cardiol. 76, 533–546 (2020).
2. Puntmann, V. O. et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 5, 1265 (2020).
3. Mitrani, R. D., Dabas, N. & Goldberger, J. J. COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. Heart Rhythm 0, (2020).
4. Moulson Nathaniel et al. SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes. Circulation 0,.
5. Joy George et al. Prospective Case-Control Study of Cardiovascular Abnormalities 6 Months Following Mild COVID-19 in Healthcare Workers. JACC Cardiovasc. Imaging 0,.
6. Johansson Madeleine et al. Long-Haul Post–COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome. JACC Case Rep. 3, 573–580 (2021).
7. Blitshteyn, S. & Whitelaw, S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients. Immunol. Res. 1–6 (2021) doi:10.1007/s12026-021-09185-5.
8. Mar, P. L. & Raj, S. R. Postural Orthostatic Tachycardia Syndrome: Mechanisms and New Therapies. Annu. Rev. Med. 71, 235–248 (2020).