A new consensus document from five subspecialty associations within the European Society of Cardiology gives recommendations for managing the cardiovascular consequences of COVID-19, spanning the acute and chronic phases, as well as adverse reactions to vaccines.
A key focus is patients who continue to have cardiovascular problems months to years after clearing a SARS-CoV-2 infection—ie, cardiac long COVID. Signs and symptoms of the condition—including angina, breathlessness, arrhythmias, heart failure, autonomic dysfunction, fatigue, and dizziness—overlap with other medical issues, making diagnosis difficult.
Vassilios Vassiliou, MBBS, PhD (University of East Anglia, Norwich, England), lead author of the statement, told TCTMD it can be a “long journey” across multiple specialists before a patient with nonspecific symptoms is diagnosed with long COVID. “Getting the diagnosis of long COVID is not easy because the underlying pathology for each patient could well be different.”
It’s estimated, he said, that 20 to 50 million people around the world—or more—may have cardiac long COVID.
“We felt we needed a formal document through the European Society of Cardiology where we could highlight symptoms that could associate with cardiac long COVID, [provide] a suggested pathway of investigation, and importantly, identify management that has some evidence and by default also discuss treatments that are being offered that do not have any evidence and could in fact bring the patients to the harm,” Vassiliou said.
We wanted to write this document so patients and healthcare professionals could learn a little bit more about cardiac long COVID and hopefully find it easier to manage patients more quickly, accurately, and safely. Vassilios Vassiliou
The consensus statement, published this week in the European Journal of Preventive Cardiology, was written by representatives of the European Association of Preventive Cardiology, the European Association of Cardiovascular Imaging, the Association of Cardiovascular Nursing & Allied Professions, the European Association of Percutaneous Cardiovascular Interventions, and the Heart Failure Association.
Prevention, Cardiac Rehab, and Vaccination
It became clear in the early days of the COVID-19 pandemic that acute SARS-CoV-2 infection was associated with myriad cardiovascular effects, including myocarditis or pericarditis, acute MI, stroke, venous thromboembolism, vasospasm, arrhythmias, and heart failure, with the risk of some of these issues lingering for months or years.
Much has been learned about preventing or mitigating the severity of these effects, and Vassiliou et al set out to provide evidence-based advice on managing the cardiovascular consequences of COVID-19 and its vaccines. A previously published systematic review on CVD as part of long COVID formed the foundation of the evidence included in the consensus statement, with additional studies published since then included as well.
The document includes sections in CV prevention after acute SARS-CoV-2 infection and in patients with prior COVID-19, cardiac rehab, investigation and treatment of cardiac long COVID, CV prevention after adverse reactions to COVID-19 vaccines, measures to prevent or reduce the severity of long COVID, and the resumption of physical activity and sports after infection with the virus. There are figures detailing an exercise training schedule for patients with long COVID and the noninvasive imaging tests that can be used to investigate possible long COVID, in addition to a table listing suggested investigations for specific clinical scenarios.
Regarding CV prevention after COVID-19, Vassiliou et al highlight the importance of “early and proactive” management of risk factors like high blood pressure, diabetes, and dyslipidemia with both medications and lifestyle modification.
“We know that individuals with uncontrolled risk factors are more likely to get long COVID and probably more likely to have long COVID for longer,” Vassiliou said.
With a focus on cardiac long COVID, he said, “what we wanted was for patients and healthcare professionals to be aware of this, reach the diagnosis of long COVID earlier, and importantly, consider personalized treatment for the patients—risk factor modification, vaccination when it’s appropriate, and tailored cardiac rehabilitation.”
The approach to cardiac long COVID depends on the etiology of cardiovascular complications. Patients with cardiac effects stemming from COVID-related injury to the heart—like acute MI, myocarditis, or heart failure—should have those conditions managed according to disease-specific clinical guidelines, Vassiliou said.
For patients with breathlessness, chest pain, or fatigue that is not related to any specific etiology, however, a tailored cardiac rehab program that supports both physical and mental health and gradually improves functional capacity could work well, he said.
“Equitable access to these programs should be prioritized, particularly for individuals from rural or socioeconomically disadvantaged backgrounds, who remain underrepresented in rehabilitation services,” the authors write.
Regarding COVID-19 vaccination, Vassiliou et al point to the well-established benefits, including reductions in acute severe illness, hospitalizations, and complications. But they acknowledge, too, the potential for rare complications like myocarditis, pericarditis, thromboembolism, and others.
Nonetheless, they write, “COVID-19 vaccines significantly reduce the severity of acute illness and long COVID. As such, shared decision-making and further booster vaccination may be of benefit in patients with prior complications, potentially with an alternative vaccine type, especially if deemed at high risk from the acute infection or long COVID.”
Further Research Still Needed
Vassiliou and his colleagues underscore the need for additional research to help refine management of cardiovascular issues in the context of COVID-19.
An important area in need of more data includes pharmacological therapy that can reduce the duration and severity of long COVID, Vassiliou said, noting that suggestions of the benefit of antiviral medications in observational studies require confirmation in randomized trials. Anti-inflammatory drugs also hold promise, he added.
In addition, the field requires more evidence on how long the excess cardiovascular risk lasts in patients with long COVID, Vassiliou said. It’s known now that patients with long COVID are two to four times more likely to have an MI or stroke over the next 2 or 3 years, but it’s unclear whether that risk persists over the longer term or can be modified.
“Future studies must prioritize optimizing prevention and rehabilitation strategies, addressing existing knowledge gaps, and delivering evidence-based recommendations to manage the evolving cardiovascular burden of the pandemic effectively,” the authors conclude.
