What is the recommended treatment for patients with Long Covid (Coronavirus disease 2019) experiencing cardiac issues?

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Last updated: July 24, 2025 • View editorial policy

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Treatment for Long COVID Cardiac Issues

For patients with Long COVID experiencing cardiac issues, treatment should focus on the specific cardiac manifestation, with corticosteroids recommended for those with myocarditis and COVID-19 pneumonia requiring supplemental oxygen, and standard heart failure therapies for those with cardiac dysfunction. 1

Diagnostic Approach

Initial evaluation of patients with suspected cardiac involvement in Long COVID should include:

  1. Basic cardiac testing 1:

    • ECG
    • High-sensitivity cardiac troponin (cTn)
    • Echocardiogram
    • Ambulatory rhythm monitoring
    • Chest imaging (X-ray and/or CT)
    • Pulmonary function tests when appropriate

  2. Advanced imaging for specific indications:

    • Cardiac MRI is recommended for hemodynamically stable patients with suspected myocarditis 1
    • Chest CT should be considered at 3-6 months in patients with dyspnea or abnormal pulmonary function tests 1

Treatment Algorithm Based on Cardiac Manifestation

1. Myocarditis

  • Mild to moderate myocarditis: Hospitalization recommended, ideally at an advanced heart failure center 1
  • Fulminant myocarditis: Management at centers with expertise in advanced heart failure, mechanical circulatory support, and other advanced therapies 1
  • With COVID-19 pneumonia requiring oxygen: Corticosteroids 1
  • With pericardial involvement: NSAIDs, colchicine, and/or prednisone for chest pain and inflammation 1
  • With hemodynamic compromise or MIS-A: Consider intravenous corticosteroids 1
  • Follow-up: Surveillance testing (ECG, echocardiogram, ambulatory rhythm monitor, CMR) 3-6 months after presentation 1

2. Heart Failure

  • Initiate guideline-directed medical therapy for heart failure before discharge and titrate as appropriate in the outpatient setting 1
  • For mildly reduced LV function with stable hemodynamics: Consider low-dose aldosterone system inhibitors 1
  • For patients with supraventricular arrhythmias who are hemodynamically stable: Consider beta-blockers 1

3. Pericarditis

  • NSAIDs as first-line treatment 1
  • Add low-dose colchicine or prednisone for persistent chest pain 1
  • Taper dose based on symptoms and clinical findings 1

4. Post-Acute Sequelae of COVID-19 with Cardiovascular Symptoms (PASC-CVS)

  • For patients with tachycardia, exercise intolerance, palpitations, chest pain, and dyspnea without objective evidence of cardiovascular disease:
    • Focused cardiac ultrasound study (FoCUS) is recommended to reduce duration of exposure 1
    • Consider cardiology consultation for persistent symptoms 1

Special Considerations

Activity Restrictions

  • Avoid strenuous physical activity for 3-6 months after myocarditis 1
  • Return to play decisions should be based on:
    1. Absence of cardiopulmonary symptoms
    2. Resolution of laboratory evidence of myocardial injury
    3. Normalization of LV systolic function
    4. Absence of spontaneous/inducible cardiac arrhythmias on ECG monitoring and exercise stress testing 1

High-Risk Patients Requiring Cardiology Consultation

  • Patients with abnormal cardiac test results
  • Known cardiovascular disease with new or worsening symptoms
  • Documented cardiac complications during SARS-CoV-2 infection
  • Persistent cardiopulmonary symptoms not otherwise explained 1

Pitfalls and Caveats

  1. Avoid unnecessary imaging: Echocardiography should not routinely be performed in all patients with COVID-19 disease 1

  2. Risk of contamination: The risk of contamination during transesophageal echocardiography is very high—consider repeat TTE, CT scan, or CMR as alternatives 1

  3. Beta-blockers caution: While beta-blockers may help with supraventricular arrhythmias, they can precipitate cardiogenic shock in patients with greater compromise of cardiac function 1

  4. Distinguishing causes: Cardiac symptoms must be objectively assessed to differentiate cardiac from neural (autonomic) etiology, as many Long COVID symptoms may be related to autonomic dysfunction 2

  5. Follow-up importance: Surveillance testing is critical to gauge recovery of cardiac function and inflammation, guide heart failure management, and assess prognosis 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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