The American College of Cardiology (ACC) has issued an expert consensus decision pathway for the evaluation and management of adults with cardiovascular consequences of COVID-19.
The document discusses myocarditis and other types of myocardial involvement, patient-centred approaches for long COVID and guidance on resumption of exercise following COVID-19. The clinical guidance was published in the Journal of the American College of Cardiology (JACC).
“The best means to diagnose and treat myocarditis and long COVID following SARS-CoV-2 infection continues to evolve,” said Ty Gluckman (Providence St Joseph Health, Renton, USA) co-chair of the expert consensus decision pathway. “This document attempts to provide key recommendations for how to evaluate and manage adults with these conditions, including guidance for safe return to play for both competitive and non-competitive athletes.”
Although rare, myocarditis with COVID-19 is more commonly seen in men. Because myocarditis is associated with a higher risk of cardiac complications, a proactive management plan should be in place to care for these individuals, according to the guidance. For patients with mild or moderate forms of myocarditis, hospitalisation is recommended to closely monitor for worsening symptoms, while undergoing follow-up testing and treatment. Patients with severe myocarditis should ideally be hospitalised at centres with expertise in advanced heart failure, mechanical circulatory support and other advanced therapies, the guidance adds.
Post-acute sequelae of SARS-CoV-2 infection (PASC)—commonly referred to as long COVID—is a condition reported by up to 10‒30% of infected individuals. It is defined by a constellation of new, returning or persistent health problems experienced by individuals four or more weeks after COVID-19 infection. While individuals with this condition may experience wide-ranging symptoms, tachycardia, exercise intolerance, chest pain and shortness of breath represent some of the symptoms that draw increased attention to the cardiovascular system.
The writing committee has proposed two terms to better understand potential aetiologies for those with cardiovascular symptoms:
- PASC-CVD, or PASC-Cardiovascular Disease, refers to a broad group of cardiovascular conditions (including myocarditis) that manifest at least four weeks after COVID-19 infection.
- PASC-CVS, or PASC-Cardiovascular Syndrome, includes a wide range of cardiovascular symptoms without objective evidence of cardiovascular disease following standard diagnostic testing.
In general, patients with long COVID and cardiovascular symptoms should undergo evaluation with laboratory tests, ECG, echocardiogram, ambulatory rhythm monitor and/or additional pulmonary testing based on the clinical presentation. Cardiology consultation is recommended for abnormal test results, with additional evaluation based on the suspected clinical condition (e.g., myocarditis).
“There appears to be a ‘downward spiral’ for long COVID patients. Fatigue and decreased exercise capacity lead to diminished activity and bedrest, in turn leading to worsening symptoms and decreased quality of life,” said Nicole Bhave (University of Michigan Health System, Michigan, USA) co-chair of the expert consensus decision pathway. “The writing committee recommends a basic cardiopulmonary evaluation performed upfront to determine if further specialty care and formalised medical therapy is needed for these patients.”