We are now years into the COVID-19 pandemic. In Los Angeles, there are still patients who have only ever experienced long COVID. Many even had mild cases. There are long COVID symptoms that include an elevated heartbeat, fatigue, lightheadedness during and after exertion, and chest pain and discomfort. As a surgeon, I have some understanding. These symptoms are often dismissed and have a negative impact on patients’ abilities to function in life.
Dr. Maria Tehrani is a cardiac surgeon and evaluates patients at the Ronald Reagan UCLA Medical Center in Westwood who have COVID-related concerns and cardiac symptoms.
What are the Effects of COVID on the Heart
COVID-19 can have a range of effects on the cardiovascular system.
– Myocarditis
– Pericarditis
– Microvascular dysfunction
– POTS and other autonomous dysfunctions
– Clotting and increased risk of embolisms
– Worsening of pre-existing heart conditions
While most people will recover from COVID, some, especially long haulers, will experience some of these effects if they don’t take it easy and avoid stressing their body by working out and living life as if they are fully recovered.
Myocarditis After COVID
Myocarditis is a COVID-related inflammation of the heart muscle and is a wide-ranging condition that can be as mild as having no symptoms to severe cases. The symptoms can also include pains that are sharp or pressure-like and can be accompanied by shortness of breath, fatigue, and low tolerance for exertion.
The danger of myocarditis occurs in the period right after the infection and after someone infected has returned to higher intensity levels of activity. This is the reason that Los Angeles athletes are advised to retrain after having COVID, and must get medical advice if symptoms occur.
Myocarditis occurs with a small number of people, and for this small number, there are changes in heart function that require more care.
POTS and Autonomic Dysfunction
One common, though not well understood, long-COVID cardiac pattern is POTS. This is actually a disorder of the autonomic nervous system. This is the part of the body that controls heart rate and blood pressure.
Patients suffering from post-COVID POTS describe:
– Heart rates that jump when standing (by 30–50 beats)
– Lightheadedness with near syncope
– Extreme fatigue that is not related to activity level
– Brain fog and difficulty focusing
– Headaches and changes in sight that occur when standing
– Symptoms that worsen when hot
This especially is a problem in Los Angeles in the summer.
It’s important to note that POTS is not a problem with the heart muscle. The heart is healthy and there are no structural problems with the heart. Unfortunately, the symptoms are very severe and many patients are told they have a heart problem when in fact, the diagnosis is not being properly considered.
Fast Heart Rate and Inappropriate Sinus Tachycardia
A higher than normal resting heart rate (sometimes referred to as inappropriate sinus tachycardia) is seen in many LA patients after COVID. An example of this is a patient who normally had a resting heart rate in the 60s, which is now in the 80s and 90s, sees palpitations that occur intermittently, and who feels that exercise is more difficult.
This pattern is also seen in POTS, and can occur on its own. It usually gets better over months, but checking to see if there are other causes and to give guidance on how to safely increase activity is helpful.
Chest Pain After COVID and Microvascular Dysfunction
Chest pain after COVID is common, and is usually more of a pain than a problem. In many cases, it is caused by anxiety, deconditioning, or simply musculoskeletal pain. However, in some cases, it is caused by microvascular dysfunction, which is when the heart’s small blood vessels do not dilate during exercise.
Traditional angiograms will not show this dysfunction, because larger arterial blockages will be normal. Sometimes specialized testing can be more helpful for this case, but the good news is that microvascular dysfunction is usually a diagnosis that gets better over time, with exercise that is guided to be more and more blood pressure and cholesterol friendly.
Who is Most Likely to Have Long Term Symptoms?
Excessive and lingering symptoms after a COVID infection is most common among patients with:
– A more severe initial COVID infection
– Multiple COVID infections
– An autoimmune or autoimmune-adjacent condition
– A pre-existing cardiovascular or chronic condition (e.g. diabetes)
– Stress, burnout, and sleeping problems during and after the infection
– POTS (mostly women, especially those under 50)
– Symptoms of a disease after COVID infection that require long term treatment
The time that recovery takes after a COVID infection is variable, from weeks to months.
What is a Reasonable Workup?
After COVID infection, if there are still cardiac symptoms present for four to six weeks, a workup will be reasonable. A workup could include:
– Baseline EKG
– Echocardiogram
– Cardiac MRI (only when there’s a concern for myocarditis)
– Short or long term Holter monitoring
– POTS workup (e.g. tilt table test or active stand test)
– Blood tests and biomarkers
– Stress test (only when there are significant exertional symptoms)
The intention is to target the workup to the symptoms to rule out any treatable conditions, not to have an exhaustive workup.
What Helps Recovery
Long COVID cardiac symptoms don’t have a quick cure. A few systems used regularly can lead to gradual recovery.
– Pacing. Work at your symptoms level. Increase your activity slowly.
– Hydration & salt. Increasing salt intake & hydration has helped people with POTS. It can help you too. Discuss this with your doctor.
– Sleep. The autonomic nervous system can help you recover if you sleep. Late night screen usage in LA does the opposite of recovery.
– Gradual reconditioning. Exercise can be done while recumbent to start the recovery. To begin upright exercise, try recumbent bikes, swimming, and mat work.
– Compression garments. These can help some patients suffering from POTS.
– Other recovery methods. Breathing practices, outdoor activities, and rests all help recovery too.
– Other symptoms. Anemia and other symptoms can worsen your POTS.
Medications that can help balance your heart rhythm and your autonomic nervous system are an option. Discuss these with a long COVID knowledgeable cardiologist.
When to See a Cardiac Specialist
You should consult a cardiac specialist if you have the following:
– Chest Pain from COVID
– Palpitations or fast heart rate with no cause
– Lightheadedness or fainting
– Reduced exercise tolerance weeks post COVID
– New heart symptoms post long COVID
– Myocarditis and questions about activity
Other emergencies like severe chest pain, signs of stroke, or fainting require you to call 911.
Long COVID heart issues are often ignored, but you can get treatment. Dr. Maria Tehrani provides detailed assessments and gives care to those with persistent heart issues in Los Angeles after a COVID infection. You will be heard.
