What is the management approach for a patient with post-COVID (Coronavirus disease) symptoms persisting for several months with a normal Chest X-Ray (CXR) and Electrocardiogram (EKG)?

Management of Post-COVID Shortness of Breath with Normal CXR and EKG

For a patient with persistent post-COVID dyspnea and normal initial testing (CXR and EKG), proceed with additional diagnostic workup including echocardiogram, ambulatory rhythm monitoring, pulmonary function tests, and cardiac troponin, followed by cardiology consultation if symptoms persist beyond 3 months or any testing is abnormal. 1

Initial Diagnostic Approach

Your patient has Post-Acute Sequelae of SARS-CoV-2 infection (PASC), defined as symptoms persisting ≥4 weeks after acute infection. 1 The normal CXR and EKG are reassuring but insufficient to exclude cardiovascular or pulmonary pathology, as these tests have limited sensitivity for detecting the spectrum of post-COVID complications. 1

Required Additional Testing

Complete the following workup systematically:

• Basic laboratory testing including cardiac troponin (cTn) to assess for ongoing myocardial injury 1
• Echocardiogram to evaluate for diastolic dysfunction (present in up to 55% of symptomatic patients), reduced ejection fraction (up to 16%), pulmonary hypertension (up to 10%), and pericardial abnormalities 1
• Ambulatory rhythm monitor (24-48 hour Holter or event monitor) to detect arrhythmias and postural orthostatic tachycardia syndrome 1
• Pulmonary function tests to identify restrictive or obstructive patterns not visible on plain radiography 1
• Chest CT at 3-6 months if dyspnea persists or PFTs are abnormal, as 59% of post-COVID patients show CT abnormalities (ground-glass opacities, fibrotic changes) despite normal chest x-rays 1

Critical pitfall: Do not measure cardiac troponin within 24-48 hours of strenuous exercise, as physiologic elevation occurs and confounds interpretation. 2

Cardiology Consultation Criteria

Refer to cardiology if the patient has: 1

• Any abnormal cardiac test results from the workup above
• Known cardiovascular disease with new or worsening symptoms
• Documented cardiac complications during acute SARS-CoV-2 infection
• Persistent cardiopulmonary symptoms (dyspnea, chest pain, palpitations) that remain unexplained after initial testing

This patient with persistent dyspnea beyond several months meets criteria for cardiology referral even with normal initial testing. 1

Symptomatic Management While Awaiting Workup

Exercise Prescription

Begin with recumbent or semi-recumbent exercise (rowing, swimming, cycling) for 5-10 minutes daily at an intensity allowing full sentences, as upright exercise may worsen orthostatic intolerance and tachycardia. 1, 2

• Increase duration by approximately 2 minutes per day each week as tolerated 2
• Transition to upright exercise only after orthostatic symptoms resolve 1, 2
• Never exercise with fever, systemic symptoms, or during acute illness exacerbations 2

Pharmacologic Options for Symptom Relief

Consider empiric trial of medications for tachycardia, palpitations, and orthostatic symptoms: 1

• Beta-blockers (first-line for tachycardia and palpitations)
• Nondihydropyridine calcium-channel blockers (alternative for rate control)
• Ivabradine (selective heart rate reduction without blood pressure effects)
• Fludrocortisone and midodrine (for orthostatic hypotension)

Non-Pharmacologic Interventions

• Salt and fluid loading may provide symptomatic relief for tachycardia, palpitations, and orthostatic hypotension 1
• Patient education on pacing activities and avoiding post-exertional malaise 3, 4

Understanding the Pathophysiology

Post-COVID cardiovascular syndrome (PASC-CVS) represents a heterogeneous disorder with widely-ranging cardiovascular symptoms without objective evidence of cardiovascular disease using standard diagnostic testing. 1 This dissociation between symptoms and initial testing explains why your patient has persistent dyspnea despite normal CXR and EKG. 5

The mechanisms likely involve: 4, 6, 5

• Persistent inflammatory reactions and immune dysregulation
• Microvascular dysfunction not visible on standard imaging
• Autonomic dysfunction causing exercise intolerance
• Possible mast cell activation syndrome in some patients

Advanced Imaging Considerations

If symptoms persist despite negative initial workup and empiric management:

• Cardiac MRI should only be performed on a case-by-case basis with a specific clinical question (e.g., ruling out myocarditis in athletes returning to high-level activity) 1
• Cardiac MRI abnormalities occur in 19-71% of recovering patients at 1-4 months but often do not correlate with symptoms and may resolve spontaneously by 6 months 1

Important caveat: The ESCMID guidelines note that evidence is insufficient to routinely recommend for or against advanced cardiac imaging in all post-COVID patients with dyspnea. 1 Reserve cardiac MRI for cases where management would change based on results.

Prognosis and Follow-up

Most post-COVID symptoms improve over time with supportive care and gradual return to activity. 3, 4 However, regular follow-up is essential to:

• Monitor symptom progression and functional capacity
• Reassess for development of objective cardiac or pulmonary abnormalities
• Adjust treatment strategies based on response
• Provide ongoing reassurance and support 3, 4

The multidisciplinary approach should address physical rehabilitation, mental health support, and management of underlying comorbidities. 3, 4