New information regarding COVID-19 continues to emerge daily. This content has been updated and is based on the sources available at the time of writing.

As evidence of COVID-19's involvement in cardiac complications continues to emerge, the literature has introduced the need for ongoing surveillance of patients who have recovered from known and suspected infections — even when those infections were mild and occurred months ago. It's now becoming clear that a post-acute COVID-19 syndrome, also called long COVID-19, is something cardiologists and other clinicians will have to manage for years to come.

One study in JAMA Cardiology, for example, found that 78% of a 100-patient cohort experienced abnormalities in cardiac MRI, with the most common being myocardial inflammation at 60%.¹ Detectable troponin was found in 71% of patients—more than twice the rate estimated in a white paper in the Journal of the American Heart Association, which was capped at 27.8%.² The median time between COVID-19 diagnosis and MRI was 71 days, and most patients recovered at home instead of the hospital.

That paper stirred concern among both patients and providers, inspiring new dialogue around the long-term consequences of a virus initially thought to be isolated to the respiratory system.

Unlike previous research in the Heart Rhythm Journal, which affirmed COVID-19's risk of acute ischemic damage in hospitalized patients,³ the JAMA Cardiology paper added new worries to the conversation by discussing potential long-term effects in otherwise healthy people who have experienced a mild form of COVID-19.

Since it was published, additional studies have revealed that the concerns were justified. Experts from the American College of Cardiology reviewed both the intermediate and long-term cardiovascular consequences of COVID-19 and identified research indicating that up to 80% of hospitalized patients reported at least one lingering cardiopulmonary or neurologic symptom 50 days after their initial diagnosis.⁴

In addition, a study in the Lancet using data out of Wuhan, China, where COVID-19 first emerged before spreading across the world, indicates that the effects of the infection may be even longer-lasting, as fatigue and muscle weakness were commonly seen 6 months after hospitalization.⁵ A review in Cardiology Journal notes that "although cardiovascular imaging was not a part of this study, it is likely that at least a part of patients who reported the fatigue and muscle weakness might have developed cardiac dysfunction."⁶

A New Wave of Cardiac Patients

These new insights suggest that a wave of heart patients may need care post-recovery to counteract potential long-term cardiac issues. These can include conditions such as cardiomyopathy, cardiac arrhythmias, chest pain, and dyspnea, which can occur alongside neurologic symptoms and mental health concerns, according to a perspective in Nature Reviews Cardiology.⁷

As trends tying COVID-19 to such conditions take shape, they are reinforcing the need for ongoing surveillance in the wake of what the Heart Rhythm Journal researchers now call "post-COVID-19 cardiac syndrome," and hospitals have begun setting up specialized clinics to monitor and care for these patients.

Exactly what that surveillance would and should look like is still under investigation, but one thing is clear: diagnostic tools such as ECG offer a fast, portable, accessible and convenient testing option for patients of all risk levels.

Using ECG to Identify COVID-19's Cardiac Complications

While hospitalized COVID-19 patients may have the benefit of lab testing, echocardiography and advanced imaging at the point of care, patients who have recovered from a mild infection may not have baseline cardiac metrics for reference. Still, knowing a patient's history of suspected or confirmed COVID-19 infection can help inform diagnostic planning well beyond recovery of the acute illness. Moreover, prior COVID-19 may come into play when considering a patient's cardiovascular fitness for various procedures. For instance, recommendations recently released in JAMA Surgery suggest that a previous bout with COVID-19, assessed as part of a preoperative risk assessment. can inform the timing of elective noncardiac surgery.⁸If medical history and physical exam warrant an ECG, clinicians will want to familiarize themselves with abnormalities that may indicate lasting complications from a COVID-19 infection, particularly arrhythmias (Afib specifically), sinus tachycardia, and conduction defects due to myocarditis. This article contains ECG indicators for each category of complications.

To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.

Other Ways the Pandemic Has Affected Cardiac Care

The impact of elective surgery deferment and postponement of necessary cardiac care in the acute setting could have long-term consequences. Not only have guidelines-based interventions been paused in various locales during the initial stages of COVID-19 and subsequent waves—including that of the fast-spreading Omicron variant—but patients themselves have also been more reluctant to visit the emergency department. Beth Israel's Cardiac Critical Care Unit, for example, experienced heart attack declines in its ED of 33%, as the Harvard Gazette reports.⁹

These trends paint a troubling picture of patients experiencing acute injury that advances into lasting damage. While more research is needed, growing evidence of long-term cardiovascular consequences tied to COVID-19 underscores the need for more diligence in diagnostic decision-making.

Indeed, the ramifications of post-COVID-19 cardiac syndrome may persist for some time. Fortunately, ECG will always be there to help identify abnormalities that may come with new waves of cardiac patients.

References:

Puntmann V, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). Journal of the American Medical Association. July 2020; 5(11): 1265-1273. https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916
Gupta AK, Jneid H, Addison D, et al. Current perspectives on coronavirus disease 2019 and cardiovascular disease: A white paper by the JAHA editors. Journal of the American Heart Association. Apr. 2020; 9: e017013. https://www.ahajournals.org/doi/pdf/10.1161/JAHA.120.017013
Mitrani RD, Dabas N, Goldberger JJ. COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. HeartRhythm. June 2020; 17(11): 1984-1990. https://www.heartrhythmjournal.com/article/S1547-5271.%2820%2930625-1/fulltext
Chilazi M, Duffy E, Thakkar A, Michos ED. Intermediate and long-term impact of COVID-19 on cardiovascular disease. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2021/04/21/13/08/intermediate-and-long-term-impact-of-covid-19-on-cardiovascular-disease. Accessed Feb. 3, 2022.
Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. January 2021; 397 (10270): 220-232. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32656-8/fulltext
Gasecka A, Pruc M, Kukula K, et al. Post-COVID-19 heart syndrome. Cardiology Journal. April 2021; 28(2): 353-354. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078939/
Satterfield BA, Bhatt DL, Gersh BJ. Cardiac involvement in the long-term implications of COVID-19. Nature Reviews Cardiology. October 2021. https://www.nature.com/articles/s41569-021-00631-3
Rohatgi N, Smilowitz NR, Reejhsinghani R. Perioperative cardiovascular considerations prior to elective noncardiac surgery in patients with a history of COVID-19. JAMA Surgery. January 2022. https://jamanetwork.com/journals/jamasurgery/fullarticle/2788012
Powell A. Stroke, heart-attack cases plummet during pandemic. The Harvard Gazette. https://news.harvard.edu/gazette/story/2020/05/dramatic-drops-in-er-visits-likely-led-to-uncounted-deaths/. Accessed Feb. 3, 2022.

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