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Long COVID, Your Heart and Cardiovascular Complications

Long COVID sequelae can have abiding effects on your heart

By Barbra Williams Cosentino

There's a reason that lacy Valentines, heart-shaped candies, emojis, pillows, and other similarly designed ephemera are so popular. It's because, aside from its importance in love, drama, poetry, and myth, the heart is fantastic. 

A close-up photo of a model of a human heart. Next Avenue, long COVID heart issues
Many people could have chronic cardiovascular conditions due to a COVID-19 infection – even patients without previous cardiovascular disease   |  Credit: Jesse Orrico

About the size of two clenched fists, an adult's heart weighs approximately ten ounces, a bit more or less depending on your body size. This four-chambered main organ of the cardiovascular system, situated between your right and left lungs, functions in tandem with the nervous and endocrine system and comprises several different parts, including valves, blood vessels, muscular tissue, and an electrical conduction system.

It pumps blood through three blood vessels — arteries, veins, and capillaries — to all body parts, controls your heart rate, and maintains your blood pressure. When it works well, it's an elegantly designed, highly functional organ that plays an integral role in keeping your body functioning like a well-oiled machine.

COVID-related cardiovascular complications might arise or persist weeks or months after resolution of the acute infection.

But despite its powerful biological functions, COVID-19 can affect your heart and cardiovascular system, not only when first stricken with the viral illness but for months and even years afterward.

What Research Says

A June 2022 report on PASC, the medical term for long COVID, by the American Academy of Physical Medicine and Rehabilitation found that COVID-related cardiovascular symptoms and complications might arise or persist weeks or months after the resolution of the acute infection.

The risk and one-year burden of cardiovascular diseases in survivors are substantial and increase according to the severity of the initial illness and the required care – whether the patient is hospitalized, treated at home, or admitted to intensive care.

According to Jonathon H. Whiteson, MD, a physiatrist, lead author of the statement, and Medical Director, Cardiac Rehabilitation and Pulmonary Rehabilitation at NYU Langone Medical Center in N.Y, "unfortunately, many people could have chronic cardiovascular conditions due to COVID 19 infection — even patients without previous cardiovascular disease or comorbidities with an otherwise low risk of cardiovascular disease."

And, he explains, symptoms such as shortness of breath, chronic cough, dizziness, and chest pain may hint at cardiovascular disease even in the absence of objective evidence such as that expected on cardiac imaging.

Among survivors of COVID-19, the AAPM&R statement reiterates that 5%-29% report cardiovascular-related symptoms. Ongoing chest pain is seen in 10-20% of long COVID patients 30-60 days after the acute infection, and dyspnea (shortness of breath and air hunger) is reported in up to 30% of patients.

"Because of the chronic nature of cardiovascular conditions, there will likely be long-lasting consequences for patients and health systems worldwide."

In addition, individuals with PASC-related cardiovascular disease may undergo fatigue, abdominal bloating, leg swelling, and impaired activity tolerance.

This compendium of symptoms derived from cardiovascular complications includes myocardial injury, acute heart failure, strokes, dysfunction or dilation (enlargement) of the heart's right ventricle (chamber), arrhythmias, and venous thromboembolism. 

Another analysis of data from nearly 154,000 U.S. veterans who had COVID infection by researchers at the Veterans Affairs St. Louis Health Care System found that in the year after recovering from the illness's acute phase, patients were at increased risk of cardiovascular disorders, including abnormal heart rhythms, myocarditis (heart muscle inflammation,) vasculitis (inflammation of the lining of blood vessels) blood clots, strokes and other thromboembolic diseases, myocardial infarction (heart attack), coronary heart disease, and heart failure. 

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In the same study, patients with more severe diseases were at higher risk, though, surprisingly, risks were evident even among those who had not been hospitalized with COVID-19.

Essential goals for treating long COVID patients include improving function and restoring quality of life.

Likewise, the sub-group analysis found elevated risks of PASC-related cardiovascular symptoms for people of all ages, races, and sexes, irrespective of whether or not there was a previous history of obesity, diabetes, tobacco usage, or high cholesterol levels and chronic kidney disease. 

It is essential to understand that some PASC symptoms related to cardiovascular disease (shortness of breath, heart palpitations, syncope) can be associated with postural orthostatic tachycardia syndrome (POTS), an autonomic dysfunction frequently found in long COVID patients.

Treatment for POTS may include exercises in a recumbent position to help stabilize blood pressure and heart rate, hydration, compression stockings, sleeping with the head elevated, and resistance exercises.

Causes of Cardiovascular Disease for Long-Haulers and Treatment

The etiology of mechanisms of injury from COVID-19, which contributes to cardiovascular post-sequelae, is not entirely clear and remains an area of intense interest to researchers. Below are a few possible causes:

  • Endothelial cell infection (these cells line blood vessels)
  • Lingering damage from a direct viral invasion of cardiac cardiomyocytes
  • Alteration of multiple cell types on heart tissue
  • Autonomic dysfunction
  • Scarring of cardiac tissue
  • Increased coagulopathy (clotting)
  • A persistently elevated immune response
  • Elevated cardiac troponin levels (protein in the muscles of your heart) and the presence of microthrombi (tiny blood clots) have also been implicated

When cytokine storms, substances that regulate the body's immune response, go into overdrive, they are believed to contribute to myocardial injury by causing increased platelet clumping and eventually leading to excess clotting.

Exercise for individuals with cardiovascular disease is a standard recommendation.

Essential goals for treating long COVID patients include improving function and restoring quality of life, and addressing modifiable cardiovascular risk factors such as medication, lifestyle and dietary changes, physical activity, weight loss, smoking cessation, and other interventions that improve diabetic control and physical stamina and reduce metabolic syndrome.

Moreover, exercise for individuals with cardiovascular disease is a standard recommendation. Yet, one of the most significant symptoms for many long COVID patients, even those with no cardiovascular disease, is post-exertional malaise (PEM), marked by profound fatigue that worsens after a minimal amount of physical activity.

As a result, exercise plans utilizing energy conserving strategies and pacing techniques should be designed and monitored by an exercise physiologist or specialist who can prescribe a regimen that will not exacerbate post-exertional symptoms. And for those with new or residual cardiovascular disease, cardiac rehabilitation programs can be recommended and helpful.

Lastly, pharmacological interventions to address this range of cardiovascular complications may contain medications such as ACE inhibitors, anticoagulants (blood thinners,) beta-blockers, cholesterol-lowering medications, vasodilators, and antiplatelet agents, among others.

Because most individuals with PASC-related cardiovascular complications were infected with the alpha and delta COVID-19 variants pre-COVID vaccination or vaccine booster, it is yet to be seen if PASC and related cardiovascular complications will be as significant in fully vaccinated individuals infected with different variants. 

barbra consentino, writer
Barbra Williams Cosentino RN, LCSW, is a psychotherapist in Queens, N.Y., and a freelance writer whose essays and articles on health, parenting and mental health have appeared in the New York Times, Medscape, BabyCenter and many other national and online publications. Read More
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