Management of Cardiac Risk After COVID-19 Infection
For individuals who have had COVID-19 infection, comprehensive cardiac evaluation and risk stratification is strongly recommended due to the significant risk of cardiovascular complications, including sudden cardiac death.
Cardiac Complications of COVID-19
- COVID-19 infection can cause significant cardiovascular complications that may persist beyond the acute infection phase, including myocarditis, arrhythmias, and thrombotic events 1
- Approximately 20-30% of hospitalized COVID-19 patients develop acute cardiac injury related to direct myocardial damage or secondary hyperinflammatory responses 1
- COVID-19 affects the renin-angiotensin system through binding to ACE2 receptors, potentially leading to blood pressure alterations and cardiovascular complications 1
- Beyond the first 30 days after infection, individuals with COVID-19 remain at increased risk for cerebrovascular disorders, dysrhythmias, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure, and thromboembolic disease 2
Risk Stratification Algorithm
Initial Evaluation (For All Post-COVID Patients)
- Obtain detailed cardiac history, focusing on symptoms such as chest pain, palpitations, dyspnea, fatigue, and exercise intolerance 3
- Perform baseline ECG to detect arrhythmias, conduction abnormalities, or ST-T wave changes 3
- Check cardiac biomarkers (troponin, BNP) to assess for ongoing myocardial injury 3
- Consider echocardiography for patients with abnormal ECG, elevated biomarkers, or cardiac symptoms 3
For Patients with Suspected Cardiac Involvement
- Perform "triad testing" including ECG, cardiac biomarkers, and echocardiography 3
- Consider cardiac MRI for patients with abnormal findings on initial evaluation or persistent symptoms suggestive of myocarditis 3
- Monitor for arrhythmias with ambulatory rhythm monitoring if palpitations or syncope are reported 3
- Evaluate for thrombotic complications with appropriate imaging if clinically suspected 3
Management Recommendations
Acute Coronary Syndromes
- For patients with COVID-19 and confirmed acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is strongly recommended for 12 months 3
- For COVID-19 patients with ST-elevation myocardial infarction (STEMI), primary PCI remains the preferred reperfusion strategy when timely access is available 3
- For patients with non-ST-elevation myocardial infarction (NSTEMI), medical management is recommended with invasive approach reserved for those with high-risk features (GRACE score >140) or hemodynamic instability 3
Myocarditis and Arrhythmias
- Patients with evidence of myocarditis should avoid strenuous physical activity for 3-6 months 1
- For patients with arrhythmias, particularly those with a history of atrial fibrillation or ventricular arrhythmias, close monitoring is essential as COVID-19 may provoke recurrence 3
- Patients with marginally controlled heart rhythm disorders are at increased risk for exacerbations if infected with COVID-19 3
- Those with a history of appropriate ICD therapy for ventricular tachycardia/fibrillation should be considered high risk for adverse outcomes with COVID-19 3
Heart Failure
- Pre-existing heart failure is a significant risk factor for poor outcomes in COVID-19, with markedly greater risk for in-hospital mortality (OR: 14.48) 3
- Patients with heart failure who are decompensated and/or have poor functional status should be considered at highest risk 3
- Close monitoring of volume status and optimization of heart failure medications is essential 3
Return to Physical Activity
- For patients with confirmed or suspected cardiac involvement, a conservative, graded approach to return to physical activity is recommended 3
- Avoid strenuous exercise during acute illness and for at least 3-6 months after myocarditis 1
- Follow-up surveillance testing (ECG, echocardiogram, ambulatory rhythm monitor, cardiac MRI) is helpful to gauge recovery of cardiac function and inflammation 1
Special Considerations
Blood Pressure Management
- For post-COVID patients with myocarditis, maintain a target systolic blood pressure of 100-120 mmHg to balance adequate organ perfusion while avoiding excessive cardiac workload 1
- Avoid excessive hypotension (<100 mmHg systolic) as it may compromise coronary perfusion 1
- Higher blood pressures (>120 mmHg systolic) may increase myocardial oxygen demand and potentially worsen recovery from myocarditis 1
Anticoagulation
- COVID-19 is associated with a prothrombotic state and increased incidence of thromboembolic disease 3
- Prophylactic anticoagulation against venous thromboembolism is recommended 3
- For non-critically ill hospitalized COVID-19 patients, therapeutic-dose anticoagulation with heparin may improve outcomes 3
- For critically ill COVID-19 patients, standard thromboprophylaxis is recommended rather than therapeutic anticoagulation 3
Long-term Monitoring
- Patients who have recovered from COVID-19 should have ongoing cardiovascular risk assessment 2
- The risk and 1-year burden of cardiovascular disease in survivors of acute COVID-19 are substantial and increase in a graded fashion according to the severity of the acute infection 2
- Care pathways for those surviving acute COVID-19 should include attention to cardiovascular health and disease 2
- Follow-up surveillance with cardiac imaging and biomarkers may be necessary to detect late complications 3
Potential Pitfalls and Caveats
- Be vigilant for signs of cardiogenic shock, which may occur in patients with COVID-19-related myocarditis and require prompt intervention 1
- Myocardial injury during COVID-19 infection may have unclear etiology - consider Type I AMI, myocarditis, stress cardiomyopathy, coronary spasm, or Type II AMI due to severe illness 3
- Small patches of inflammation and/or edema can be missed on cardiac imaging and autopsy 4
- Unheralded cardiac arrest may occur in previously healthy individuals after COVID-19, highlighting the need for thorough risk stratification 4