ACC Guidance on Cardiovascular Consequences of COVID-19

The impact of the novel coronavirus (COVID-19) pandemic on the world has been unprecedented in modern times. While respiratory involvement is the characteristic presentation of infection with COVID-19, it has become increasingly apparent that cardiovascular complications are common as well. A diverse list of cardiovascular testing anomalies and complications have been reported and range from biomarker elevations and echocardiographic abnormalities to myocardial injury, thrombosis, and arrhythmias.¹

It also appears that long COVID-19 cardiovascular symptoms and laboratory findings may persist following acute illness and may include chest pain, shortness of breath, fatigue, palpitations and diagnostic results indicating myocardial injury in both symptomatic and asymptomatic COVID-19 patients.¹ In light of these facts the American College of Cardiology (ACC) thought it prudent to issue guidance with regards to three specific areas of post COVID-19 cardiovascular care: Myocarditis and other Myocardial Involvement, Post-acute Sequelae of SARS-CoV-2 Infection, and Return to Play (exercise) for athletes after COVID-19.

Myocarditis

Myocarditis is a term used to describe nonspecific inflammation of the heart muscle. It is often accompanied by symptoms such as chest pain, shortness of breath, and the feeling of palpitations. Clinically, patients with myocarditis may have variable presentations so the ACC workgroup chose to separate myocarditis into three diagnostic categories:

1. Possible myocarditis: Patients who are symptomatic with elevated troponin values and abnormal electrocardiographic and or echocardiographic findings but without positive cardiac biopsy.
2. Probable myocarditis: Features of possible myocarditis with follow-up biopsy within six months consistent with previous myocarditis.
3. Definite myocarditis: Features of possible myocarditis but with positive biopsy or cardiac resonance imagery.

Data suggests that men are at higher risk for COVID-19 related myocarditis. The workgroup recommends that patients with mild to moderate or deteriorating symptoms be hospitalized for close monitoring, follow-up testing, and treatment. Those with severe disease should be hospitalized at facilities with advanced heart failure programs and mechanical circulatory support availability.

While recognized, the development of myocarditis after a second mRNA COVID vaccine is rare. The ACC recommends that, unless contraindicated, anyone eligible for a COVID-19 mRNA vaccine should get one.

The mainstays of treatment for clinically significant myocarditis remain supportive. Beta-blocking drugs and angiotensin inhibiting medications may be used in less severe disease without significantly diminished heart function. Corticosteroids may be employed when confirmed inflammation is present. Patients in cardiogenic shock may benefit from extracorporeal membrane oxygenation (ECMO) support until the inflammation recedes. Cardiac MRI should be performed to evaluate long term damage after improvement.

Long COVID Post Acute Sequelae

Long COVID is defined by a constellation of new, returning, or persistent health problems lasting four or more weeks after COVID-19 infection.¹ This condition appears to affect as many as 10-30% of infected individuals and is characterized by fatigue, tachycardia, and exercise intolerance. The ACC workgroup suggest that these patients should undergo evaluation from a cardiovascular standpoint with additional evaluation if a specific condition such as myocarditis is suspected. Management should be targeted to specific symptoms. A “downward spiral” has been recognized whereby patients who suffer from fatigue exercise less and spend more time in bed leading to a worsening of symptoms. The workgroup suggests that low level exercise be encouraged with non-upright or recumbent exercise being used to avoid worsening fatigue. Beta blocking medications may be employed for tachycardia and nonsteroidal anti-inflammatory drugs sparingly for chest pain without evidence of ischemia.

Return To Play

The workgroup has issued guidelines for the return to competitive sports and intense exercise training. The group recommends that athletes recovering from COVID-19 with ongoing cardiopulmonary symptoms or those requiring hospitalization undergo further evaluation with electrocardiogram, troponin assays, and echocardiogram. These athletes should abstain from exercise for three to six months if diagnosed with myocarditis. Cardiac testing is not recommended for asymptomatic athletes. These athletes should abstain from training for three days to ensure that symptoms do not develop. For those with symptoms, they may return to training once symptoms resolve. Repeat cardiac testing and cardiac MRI are not recommended once symptoms have resolved.

In conclusion, the ACC continues to set the benchmarks in cardiovascular care. In this recent consensus statement on the cardiovascular implications following COVID-19 infection, the college addresses post infections myocarditis, long COVID syndrome, and returning to play for athletes infected with COVID-19. While these guidelines will undoubtedly aid clinicians in caring for patients the workgroup co-chair, Ty Gluckman, MD, MHA, warns that the best means to diagnose and treat myocarditis and long COVID continues to evolve.

Reference:

1. Gluckman, T. J., Bhave, N. M., Allen, L.A., et al. 2022 ACC Expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute Sequelae of SARS-CoV-2 infection, and return to play: A report of the american college of cardiology solution set oversight committee. J Am Coll Cardiol. Mar 16, 2022. Epublished DOI: 10.1016/j.jacc.2022.02.003