Recently, Ministry of Health and Family Welfare, Government of India released guidelines for the management of post COVID sequelae. As we enter the another year of pandemic, patients with ongoing symptoms after recovery from COVID-19 are gradually recognized as a growing population in essential of consideration. It has been found that many patients have been suffering short to long-term sequelae of the disease. Some patients have enduring sequelae/symptoms which may or may not be causally linked to COVID-19. In the absence of universally accepted definition, Post-COVID Syndrome by consensus is defined as signs and symptoms that develop during or after an infection consistent with COVID-19 which continue for more than 12 weeks and are not explained by alternative diagnosis. Recent literature also divides post-COVID patients into subacute or ongoing symptomatic COVID (4-12 weeks beyond acute COVID-19) and chronic COVID or Post-COVID syndrome (symptoms persisting beyond 12 weeks of onset of acute COVID-19). Another terminology which is in trend is the ‘Long COVID’ that is definite by National Institute for Health and Care Excellence as symptoms that continue or develop after acute COVID-19. The aim of this document is to guide doctors on managing post-COVID complications affecting cardiovascular, gastrointestinal, nephrological, neurological and respiratory systems.
Asymptomatic patients of COVID also been reported with the cardiovascular sequelae along with symptomatic patients. Up to 20%–30% of patients hospitalized with severe COVID19 have evidence of myocardial involvement manifested abnormal laboratory markers. Myocardial involvement is presumed to be the initiator of inflammatory process and subsequent fibrosis (detectable on cardiac magnetic resonance imaging) and long-term sequelae too. The long-term sequelae include increased cardio-metabolic demands, myocardial fibrosis or myocardial scar, persistent left ventricular dysfunction, heart failure, arrhythmias, inappropriate sinus tachycardia and autonomic dysfunctions. Patients who develop viral myocarditis, myocardial infarction, pulmonary embolism, stress induced myocardial injury and arrhythmias during the acute phase are at higher risk of developing long-term cardiovascular complications and poor outcomes.
The management of patients with Post-COVID cardiovascular complications be determined by the status of pre-existing cardiac comorbidities and the cardiac condition developed during the acute phase (myocardial infarction, pulmonary embolism, tachyarrhythmia etc) or during recovery of the COVID.
Impact of cardiopulmonary exercise in Post-COVID patients is not clearly known yet. However, general rules that are applicable to this subset of patients include one week of low level stretching and strengthening before exercise in patients with mild COVID-19 post recovery. In presence of mild Post-COVID symptoms, limiting exercise to slow walking and increasing rest period if symptoms worsen would be recommended. In patients with persistent symptoms (such as fatigue, cough, breathlessness, fever), limiting activity to 60% maximum heart rate (220-age in years) until 2-3 weeks after symptoms resolve. Intense cardiovascular exercise is to be avoided in all patients for 3 months. Athletes are advised to take three months of complete rest from cardiovascular training followed by specialist follow-up, with return to sport guided by functional status, biomarkers, absence of dysrhythmias, and evidence of normal left ventricular systolic function.
Patients with cardiac comorbidities/conditions such as diabetes mellitus, hypertension, obesity, atrial fibrillation and prior myocardial infarction and heart failure should be managed meticulously National Comprehensive Guidelines for Management of Post-COVID Sequelae [for doctors] as per guideline directed medical therapy. Patients with cardiovascular diseases should be on statins, antiplatelet drugs in addition to the drugs for management of their risk factors including hypertension and diabetes. Adequate treatment of cardiac risk factors such as diabetes, hypertension, obesity and dyslipidaemia in addition to the lifestyle modifications described above is the need of the hour in this ongoing pandemic to not only avoid development of new cardiac complications, but also preventing decompensation in those with pre-existing heart disease. Serial follow up of these patients biannually or annually is the key to ensure drug compliance and avoid further major adverse cardiac event. Focusing on patients with heart failure with reduced ejection fraction, the nonpharmacological treatment in people with congestive heart failure include educating people about self-management, limiting dietary sodium to < 2g/day and fluid intake to < 2 L/day (1.5 L for severe CHF), explaining the symptoms of dyspnoea, oedema and bloating and smoking cessation. They are advised to report or reach through telemedicine to their cardiologist for worsening symptoms and for regular follow-up. Prior experience suggests higher risk of cardiovascular events after revere viral infections in patients with cardiovascular disease. Data from the ongoing pandemic is scarce as of now and it is encouraged to get vaccinated for COVID-19 and pneumococcal disease. Guideline directed medical therapy for heart failure includes beta blockers, Angiotensin Converting Enzyme Inhibitors (ACE inhibitors)/Angiotensin Receptor-Neprilysin Inhibitor (ARNi)/ Angiotensin Receptor Blockers (ARB), mineralocorticoid receptor blockers and diuretics. Patients with atrial fibrillation will require anticoagulation for stroke prevention as dictated by CHA2DS2Vasc score. Patients with confirmed DVT/pulmonary embolism require anticoagulation prophylaxis preferable with novel oral anticoagulants or warfarin to maintain the INR (International normalized ratio) in the range of 2-3. In conclusion, COVID-19 impacts cardiovascular system in the recovery phase and is part of the overall Post COVID syndrome. Physicians managing Post-COVID clinics should be aware of these symptoms and cardiovascular implications of COVID-19 sequelae. Discrete screening, appropriate investigations and evidence-based treatment of cardiovascular Long COVID is mandated to reduce long term impact of COVID-19.