People with long COVID and cardiovascular symptoms may now follow a prescribed path for evaluation and treatment recommended by the American College of Cardiology (ACC).

According to the new guidance, people with post-acute sequelae of SARS-CoV-2 infection (PASC) should undergo evaluation with laboratory tests, electrocardiograms (ECGs), echocardiography, ambulatory rhythm monitoring, and/or additional pulmonary testing depending on the clinical presentation, according to Ty Gluckman, MD, MHA, of Providence St. Joseph Health in Tigard, Oregon, and colleagues of the writing group.

Abnormal test results would merit cardiology consultation and further evaluation, Gluckman’s team said in a new ACC expert consensus decision pathway, published online in the Journal of the American College of Cardiology.

Long COVID With Heart Symptoms

The statement suggests that PASC patients should be split into two groups — those with outright, documented cardiovascular disease; and those with “cardiovascular syndrome,” a heterogeneous disorder that includes a wide range of cardiovascular symptoms that cannot be explained by testing.

In the case of PASC-cardiovascular syndrome, the predominant symptom should drive evaluation and management.

People with unexplained tachycardia and exercise intolerance, for example, should avoid cardiovascular deconditioning and maintain physical activity by means of seated exercises (e.g., rowing, swimming or cycling). They can transition back to upright exercise as symptoms improve.

“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,” explained writing group co-chair Nicole Bhave, MD, of Michigan Medicine in Ann Arbor, in a press release.

When it comes to managing PASC, it doesn’t appear to be important whether heart symptoms emerged earlier (4-12 weeks after acute infection) or later, the ACC guidance says, though it does acknowledge the evolving evidence.

Myocarditis

In the same expert consensus decision pathway, Gluckman and colleagues highlighted the observation that myocarditis is rare following COVID-19 and COVID-19 mRNA vaccination.

They recommended that people with mild and moderate myocarditis alike be hospitalized for testing and close monitoring of symptoms.

“The incidence, risk factors, mechanisms, preferred diagnostic and therapeutic approaches, and prognosis for viral-mediated and mRNA vaccine-associated myocarditis remain incompletely understood,” the authors noted.

“Because of this, additional systematic, cross-sectional data are needed to describe the frequency, type, and severity of myocarditis and myocardial involvement observed. Randomized trials are also needed to better understand the preferred means to test and treat patients with myocarditis related both to SARS-CoV-2 infection and mRNA vaccination,” the authors added.

Return to Play

Finally, the ACC recommended that athletes recovering from COVID-19 undergo testing if they have cardiopulmonary symptoms. Such individuals should stick with an ECG, troponin test, and an echocardiogram — only proceeding to cardiac MRI if initial test results are abnormal — and wait for symptoms to resolve before going back to playing sports.

Asymptomatic individuals don’t need cardiac testing, but should abstain from training for 3 days to ensure that symptoms do not develop.

Individuals diagnosed with clinical myocarditis should abstain from exercise for 3-6 months.

“Based on the low prevalence of myocarditis observed in competitive athletes with COVID-19, it is also reasonable to apply these recommendations to high-school athletes (aged ≥14-15 years) along with masters-level recreational exercise enthusiasts,” Gluckman’s team wrote.

The authors cautioned that it remains unclear how long cardiac abnormalities persist following COVID-19 infection, and the role exercise training might play in long COVID.