Should an electrocardiogram (EKG) be performed on a patient with recent COVID-19 infection and symptoms of shortness of breath and dizziness?

EKG in Post-COVID-19 Patients with Shortness of Breath and Dizziness

An electrocardiogram (EKG) should be performed in patients with recent COVID-19 infection experiencing shortness of breath and dizziness, as these symptoms may indicate potential cardiac involvement that requires evaluation. 1

Rationale for EKG in Post-COVID Patients

• EKG is recommended as part of the initial evaluation when there is moderate to high suspicion for cardiac involvement in patients with COVID-19, especially those presenting with symptoms like shortness of breath and dizziness 1
• Shortness of breath and dizziness in post-COVID patients may indicate potential myocardial involvement that requires cardiac assessment 1
• COVID-19 can cause various cardiovascular manifestations including myocarditis, pericarditis, and arrhythmias that can be detected through EKG 1, 2

EKG Findings to Look For in Post-COVID Patients

• Diffuse T-wave inversion across multiple leads, which is a characteristic EKG finding in COVID-related myocarditis 2
• ST-segment elevation without reciprocal ST-segment depression, which may indicate myocardial inflammation 1, 2
• Prolongation of the QRS complex duration, which is associated with worse prognosis in myocarditis 2
• Various conduction abnormalities, including AV blocks and bundle branch blocks 2

Recommended Diagnostic Approach

1. Initial Evaluation:

   • EKG should be performed alongside cardiac troponin measurement (preferably high-sensitivity assay) and echocardiogram 1
   • This triad of tests helps determine the likelihood and severity of cardiac involvement 1

2. If EKG shows abnormalities:

   • Cardiology consultation is recommended for patients with concerning EKG findings, rising troponin levels, and/or echocardiographic abnormalities 1, 2
   • Consider cardiac MRI for hemodynamically stable patients to confirm myocardial inflammation and exclude other causes 1

3. If high-risk features are present:

   • Patients with hypotension, ventricular arrhythmias, or advanced heart block should be evaluated at an advanced heart failure center 1, 2
   • Endomyocardial biopsy may be considered in patients with clinical deterioration 1

Important Considerations and Caveats

• While EKG is recommended, unnecessary cardiac imaging should be avoided if it will not change management decisions 1
• A focused cardiac ultrasound study (FoCUS) approach is recommended if echocardiography is needed, to minimize exposure time 1
• Routine cardiac testing is not recommended for asymptomatic COVID-19 patients or those with low suspicion for cardiac involvement 1
• The absence of EKG abnormalities does not rule out cardiac involvement; clinical correlation with symptoms and other test results is essential 1, 2

Special Situations

• In patients with known pre-existing cardiovascular disease, COVID-19 can act as a cardiac stress test, potentially aggravating underlying conditions 1
• For patients with persistent symptoms after COVID-19 recovery (PASC or Long COVID), EKG should be part of the cardiac workup if cardiopulmonary symptoms are present 1

By following this approach, clinicians can appropriately identify and manage potential cardiac complications in post-COVID patients presenting with shortness of breath and dizziness, which may significantly impact morbidity and mortality outcomes.