Long-haul COVID-19 and your heart

Because it is so new, much about the COVID-19 virus remains a mystery to physicians and researchers. This is especially true for those who experience what is known as ‘long-haul’ COVID. The official name for this condition is ‘post-acute sequelae of SARS-CoV-2 infection’ (PASC). It is being reported by up to 10 to 30 percent of people infected with the virus and is defined by new, returning or persistent health problems four or more weeks after an infection.

Of these symptoms, some of the most frightening are those that affect the heart. They are also the most puzzling because test results don’t necessarily match the symptoms the way they usually do. It’s a serious enough problem that the American Heart Association has awarded more than $10 million in research grants to study the long COVID-19 impact on cardiovascular health.

The most common PASC cardiovascular symptoms are:

• Tachycardia
• Palpitations
• Chest pain
• Shortness of breath on exertion
• Exercise intolerance and fatigue
• Elevated blood pressure

“The confounding thing is that patients of all ages and genders end up in the cardiology office or primary care office with this array of symptoms, and all of the conventional tests are normal,” said Cardiologist Lawrence McAuliffe, MD, at Cape Cod Healthcare Cardiovascular Center in Hyannis.

“This is such a hard topic to talk about because it’s new,” he said. “Some of the aspects of virology and vaccination are old, but this infection is new. Its long-lasting effects appear to be more prominent than other infections and the only way to really know about a disease is to look at it ten years later, and we don’t have that luxury.”

That said, there are many plausible theories why people are having heart problems after COVID-19. The maiden organ the virus attacks is the lungs, but from there it can disseminate to many different places in the body, including the heart.

“The easiest way to visualize it is to imagine the virus getting into a cardiovascular cell, whether it’s a cell in the heart muscle or a cell in the blood vessels or nerve endings, and causing direct damage by that infiltration,” Dr. McAuliffe said. “Beyond that, and probably the more long lasting and concerning effects, are the cascade of subsequent reactions to the original infection.”

It can cause a robust anti-viral inflammatory response, but it can also cause an autoimmune-like response, he said. In that case, the body is interpreting its own cells as being foreign and so it attacks them.

“In a subacute infection, you can get a direct infection of myocardial cells which damages the heart muscle and creates a cardiomyopathy – a diffusely weakened heart muscle,” Dr. McAuliffe said. “That’s intuitively very clear. If you get an infection in your organ and it gets damaged, it doesn’t work as well. That’s an easy concept.”

It’s comparable to younger patients in his practice who have post-viral cardiomyopathy from the flu. In those cases, their heart muscle was damaged either by the infection or the response to the infection in a very similar manner. So, there is the direct infection of the cell and then there is the response of the body to fight the infection, as well as the mistaken identity autoimmune response. That in turn can affect the electrical conduction system of the heart, creating a faster than normal heart beat.

Anytime you have an injury to the body, you have inflammation followed by the healing process, and the damage caused by COVID-19 is no different, Dr. McAuliffe said. It’s comparable to a scar forming after an incision.

“If you have any damage to any of the blood vessels, they can become scarred and not elastic like they should be, so they are not dilating when they should and not restricting when they should,” Dr. McAuliffe said. “That can result in swings in blood pressure. If they’re scarred and don’t dilate well, you can be hypertensive.”

Some Symptoms Are Mysterious

Exercise intolerance or fatigue is most likely caused by a mismatch of blood flow to your body when you are trying to exercise. Normally the autonomic nervous system sends blood and oxygen to those organs, like the muscles that need it for exercise, and directs it away from your gut and kidneys because they don’t need it while you exercise. If the blood isn’t sent to the proper source, the result is exercise intolerance or fatigue.

While those symptoms have explanations, the patients who have debilitating symptoms, but test normal on all of their heart function tests are a harder puzzle to figure out.

“I’ve encountered a number of these individuals and there are several things to convey,” Dr. McAuliffe said. “After you’ve done testing and found nothing wrong, you want to provide reassurance that often nothing is damaged or wrong necessarily. You can’t explain these things well, but the overwhelming majority of people will get better over time.

“You don’t want to hold out false hope, but it’s just as important to emphasize that they’re not crazy – that just because the tests don’t suggest an abnormality to explain symptoms, you don’t tell them that they don’t have their symptoms, because they do.”

Dr. McAuliffe tries to come up with strategies and treatments that will help address the symptoms each patient is experiencing. He might suggest a gradual increase in exercise regimens over time, adequate hydration and compression stockings. Some people will need to take medication, but it doesn’t have to be for the rest of their life. It could just be for the short term.

In the big picture, Dr. McAuliffe has a positive perspective. He does not expect to see a tsunami of heart disease in the future.

“It is a world-wide pandemic and by virtue of that and how many people it has affected, there will be a discrete cohort of new patients afflicted by the consequences of that disease, either the acute infection or the long-term effects which will require evaluation and treatment,” he said.

“COVID-19 has had a terrible impact over the past two-plus years in terms of personal loss; physical, emotional and psychologic stress; and on the global economic, sociologic and scientific community. Over time, we will come to a better understanding of the disease and its consequences—acute and long-term—and thereby a better way to approach and treat it.”