Cardiovascular Complications of COVID-19:

A focus on Post-Acute Sequelae of COVID-19 (PASC)

Amanda K. Verma, MD, FACC

Assistant Professor of Medicine

Department of MedicineCardiovascular Division

Section of Heart Failure and Cardiac Transplantation

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Disclosures

• None

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Post-Acute Sequelae of COVID-19 (PASC)

• Long COVID, ”long haulers,” post COVID syndrome

• Physical and mental health consequences that are present for 4 or more weeks after SARS-CoV-2 infection1

• Includes general complications of prolonged illness/hospitalization and specific effects of SARS-CoV-2 infection

“Evaluating and Caring for Patients with Post-COVID Conditions: interim Guidance.” Centers for Disease Control. June 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-index.html

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Post-COVID Recovery

• In a study of 143 patients in Italy who were hospitalized for infection

• 73% had interstitial pneumonia during hospitalization, mean hospital LOS 13.5 days

• Assessed at mean of 60 days after onset of initial symptoms

• Only 12.6% were completely free of any symptoms

Carfi et al. Persistent symptoms in patients after COVID-19. JAMA. Aug 2020.

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PASC/Post-COVID Syndrome• Most patients have mild course of COVID-19 infection

(85%)1

• Predictors of persistent symptoms2:

1Tenforde et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-9 in multistate health care systems network – United States, March-June 2020. MMWR Morb Mortal Wkly Rep. Jul 2020. 2Carvalho-Schneider et al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clin Microbiol Infect. Feb 2021.

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Post-COVID and Myocarditis – should we be worried?

• Several papers published looking at patients recovered from COVID-19 and then underwent cardiac MRI that showed abnormalities

• Controversy as to what this means and implications

• Asymptomatic patients need CMR?

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Take away points from initial literature

• Variable presentations of patients although studies noted patients were “asymptomatic”

• Small number of patients

• Inconsistent patterns of T1/T2/LGE in unexpected distributions

• No follow-up or prior imaging

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• Healthcare workers

• Few comorbidities• 18% tobacco users

• 7% HTN

• 2% DM

• Phenotyping around 6 months post COVID+ testing

• Minimal residual symptoms

• Primary endpoints• LVEF, LVEDDi, LGE%, septal T1,

septal T2

• Secondary endpoints• LV mass, LA area, GLS, septal

ECV, aortic distensibility

• Other endpoints• HR, NT-proBNP, hsTnT, BP

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Who and when to image?

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Who and when to image?

• My practice:• Ongoing symptoms (especially chest pain) without known cause

• Abnormal TTE (reduced LVEF, abnormal strain, WMA)

• New arrhythmia (excluding sinus tachycardia)

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Cardiovascular PASC

• Blood pressure fluctuations – relative hypertension versus orthostatic hypotension

• Palpitations and tachycardia• Atrial arrhythmias

• POTS, inappropriate sinus tachycardia

• Chest pain• Plaque instability/rupture in setting of underlying risk factors

• Musculoskeletal

• Pericarditis-like pain

• Shortness of breath

• Exercise intolerance

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Underlying mechanisms of CV-PASC

• Autonomic dysfunction

• Inflammatory response

• Endothelial dysfunction, +/- microvascular dysfunction

• Direct viral jury

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Post-COVID Cardiology Clinic• Goal: comprehensive cardiac evaluation of patients with new

onset cardiac symptoms during or following COVID-19 infection

History - Symptoms at time of acute infection- Time course of symptoms- New symptoms- Medications taken at time of acute infection- Review of smart watch HR trends

Physical Exam - Orthostatic vital signs- Ambulatory heart rate

Baseline Screening Tests

- EKG- Inflammatory markers: CRP, ESR, D-Dimer, Ferritin- Cardiac biomarkers: NT-proBNP, high sensitivity

troponin

Additional Testing - TSH, free T4- PA & Lateral CXR- 6 min walk test- PFTs- Holter patch monitor- Transthoracic echocardiogram- Cardiac MRI- Stress testing

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Post-COVID Cardiology Clinic ExperienceAnecdotal Treatment Strategies

Palpitations/Tachycardia

- Low dose beta blocker (metoprolol succinate)- Ivabradine- Diltiazem – less effective

Hypertension - Carvedilol (especially if component of tachycardia)

- ACE-i/ARB- CCB (i.e. amlodipine) or MRA – less effective

POTS - Hydration, salt loading, compression stockings- Fludrocortisone

Myocarditis - Beta blocker and ACE-i/ARB - Activity restriction followed by Cardiac Rehab- NSAIDs/colchicine for chest pain

Dyspnea of unclear etiology

- Albuterol inhaler prior to exertion

Chest pain of unclear etiology

- scheduled NSAIDs- Gabapentin- colchicine

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Post-COVID Cardiology Clinic Experience

• Aspirin?• Hypercoagulability is established in acute infection

• Unclear benefit in post-COVID syndrome

• Many patients with ongoing symptoms and elevated inflammatory markers

• Oral contraceptive therapy

• Steroids?• No data in post-COVID setting, although appears helpful in MIS

• Anecdotally not helpful

• Vaccination?• No significant improvement in symptoms

• Safe for patients with history of COVID-19

• Follow-up?• How long to take medications

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COVID-19 Vaccination

• Informed consent

• BENEFITS >>>>>> Risks

Rosenblum HG et al. Use of COVID-19 Vaccines after Reports of Adverse Events Among Adult Recipients of Janssen (Johnson & Johnson) and mRNA COVID-19 Vaccines (Pfizer-BioNTech and Moderna): Update from the Advisory Committee on Immunization Practices—United States, July 2021. Morbidity and Mortality Weekly Report.

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Serious adverse events

• Johnson & Johnson:• Thrombosis with thrombocytopenia syndrome (TTS) - venous or

arterial thrombosis and thrombocytopenia

• Guillain-Barre syndrome (GBS) – autoimmune neurologic disorder characterized by ascending weakness and paralysis

• 3,000-6,000 cases reported annually

• mRNA Vaccines – Pfizer or Moderna:• Myocarditis/cardiac inflammation

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Johnson and Johnson – as of 6/30/2021

Doses administered Approx 12.6 million

GBS (between 2/27-6/30/21) • 100 cases reported, 14 confirmed

• Rate: 7.8 per 1 million (0.00078%) – 20.2/million (0.002%)

• Median age: 57• 61% males• Median time to onset 13 days• 1 death

TTS (through 7/8/21) • 38 cases• More common in females aged

30-49• Rate: 8.8 per 1 million

(0.00088%• 4 patients died

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mRNA – as of 6/30/2021

Doses administered Approx 141 million

Myocarditis • 497 cases reported• 3.5 cases per million

(0.00035%)• Highest amongst males ages

18-29• No confirmed deaths

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Benefits >>>> Risks