Dr. Gregory Weiss, a cardiovascular anesthesiologist, offers perspective on the topic of long COVID syndrome and how the prospect of this phenomenon impacts clinical settings.
The evolution of a pandemic is difficult to predict. Even with historical references and prior infectious strains, COVID-19 has proven extremely adaptable and persistent in its spread. The emergency authorization of several novel vaccines last December has given the world a chance to catch its collective breath and take stock of what has transpired over the last year and what is yet to come. Acute infection with COVID-19 aside, a new more insidious phenomenon has come to light.
As clinicians, we are seeing patients recovering from acute illness with COVID-19 only to develop long-term symptoms. This so-called long COVID syndrome may consist of mild symptoms including fatigue, shortness of breath, sleep disorders, chest pain, gastrointestinal problems, and depression or debilitating symptoms that disrupt patients’ lives and prevent them from productivity and wellbeing.
Due to the increasing numbers of long COVID patients, the National Institutes of Health has launched an initiative to research what they are now calling Post-Acute Sequelae of SARS-CoV-2 infection (PASC).1 As people come back to brick-and-mortar clinics front-line health care providers are seeing more and more PASC patients walking through their office doors. Cardiologists are among the clinicians getting involved in PASC programs providing direct patient care to long COVID patients and investigating this enigmatic and crafty condition.
Recently, the American College of Cardiology published a piece highlighting interviews with three prominent cardiologists. These front-line clinicians were asked a variety of questions about their experiences with Post-Acute SARS-CoV-2. Dr. Amanda Verma, MD cares for heart failure and cardiac transplant patients at Washington University in St. Louis, MO. When asked how long COVID patients present to her practice she cites palpitations, chest pain, dyspnea, and fatigue as the most common complaints these patients have.1 Dr. Verma states,
“These symptoms are debilitating to patients who were previously very active and now cannot walk up a flight of stairs.”
Dr. Sean P. Pinney, MD, is the co-director of the Heart and Vascular Center at the University of Chicago. Dr. Pinney states that,
“The most consistent symptom has been one of overwhelming post-exertional fatigue.”
In addition to fatigue, Dr. Pinney has also seen long COVID patients present with chest pain, palpitations, and shortness of breath long after their initial COVID-19 infections. Citing a sense of hopelessness and solitude, Dr. Pinney states,
“I believe it is critically important to listen and to validate that what (patients) they are experiencing is real.”1
Dr. Joseph Mularczyk, MD is an assistant professor of medicine at Rush Medical College in Chicago, IL. Dr. Mularczyk has found that many long COVID patients present with inappropriately rapid heart rates.1 The most interesting part, from a cardiologist’s point of view, is that these changes in heart rate don’t appear to be cardiac problems. Dr. Mularczyk believes that they represent the sequelae of neurologic involvement with the COVID infection.1
Following presentation clinicians are faced with the daunting task of evaluating their long COVID patients. All three cardiologists agree that the primary evaluation of a long COVID patient presenting with cardiac symptoms should consist of an electrocardiogram and an echocardiogram.1 These tests aim to diagnose rhythm problems and evaluate the physical function of the heart. All three physicians also cite cardiac MRI as a useful tool in revealing potential heart inflammation secondary to COVID-19.1
The final hurdle to overcome with long COVID patients consists of developing and implementing an effective treatment plan. Unfortunately, this syndrome is too new for there to be established protocols for treatment. Both Dr’s Mularczyk and Verma point to symptom management with conventional therapies like Beta Blocking drugs for tachycardia as the mainstay of treatment.1 Dr. Pinney states,
"So far, I have not found a magic bullet. I recommend graded aerobic exercise as the has seemed to lessen symptoms over time.”1
Determining risk is a strategy all physicians employ when studying any disease process. Unfortunately, all three of the cardiologists interviewed could find no specific demographic at higher or lower risk for developing long COVID syndrome.1 Dr. Mularczyk highlights this frustration in saying,
“There is no demographic which appears to be more or less vulnerable for Long COVID syndrome. Many people who have experienced only mild initial symptoms have progressed to have significant long-term symptoms.”
Finally, Dr’s Verma, Mularczyk, and Pinney stress the importance of believing patients when they come in with persistent symptoms after COVID-19 infection.1 Patients become frustrated when tests reveal nothing concrete and clinicians tell them nothing is wrong. This is a real phenomenon and patients are suffering who at one time were healthy, happy, and active. A real concern is how long these symptoms will persist. Dr. Amanda Verma sums up this uncertainty stating,
“I am worried some of these issues will become chronic conditions; but I cannot tell in whom, and we do not yet know the implication this may have for their cardiovascular health in the future.”1