What is the best treatment for a post-COVID-19 patient with shortness of breath on exertion and underlying cardiac issues, beyond using albuterol (bronchodilator)?

Treatment of Shortness of Breath in Post-COVID-19 Patients with Cardiac Issues

For post-COVID-19 patients with shortness of breath and underlying cardiac disease, prioritize non-pharmacological breathing techniques and structured pulmonary rehabilitation, while using beta-blockers cautiously only if hemodynamically stable, as they can precipitate cardiogenic shock in patients with compromised cardiac function. 1

Initial Evaluation and Risk Stratification

Before initiating treatment, perform comprehensive cardiac assessment including ECG, echocardiogram, cardiac troponin, ambulatory rhythm monitor, chest imaging, and pulmonary function tests to distinguish between cardiac dysfunction (PASC-CVD) and functional cardiovascular syndrome (PASC-CVS). 1 Cardiology consultation is mandatory for patients with abnormal cardiac test results, known cardiovascular disease with worsening symptoms, or documented cardiac complications during SARS-CoV-2 infection. 1

Non-Pharmacological Interventions (First-Line)

Breathing Techniques

Implement controlled breathing exercises as the primary intervention, which have demonstrated significant improvement in respiratory parameters even over short periods:

• Pursed-lip breathing: Inhale through nose for several seconds with mouth closed, then exhale slowly through pursed lips for 4-6 seconds to relieve breathlessness during exertion 1
• Positioning strategies: Sit upright to increase peak ventilation, lean forward with arms bracing to improve ventilatory capacity 1
• Diaphragmatic breathing and thoracic expansion exercises with huffing and coughing techniques 2

These interventions improved oxygen saturation (96.6% vs 90.7%), reduced oxygen requirements, and decreased respiratory rate in moderate to severe COVID-19 patients within 4 days. 2

Structured Exercise Rehabilitation

Begin with recumbent or semi-recumbent exercise (rowing, swimming, cycling) for 5-10 minutes daily, gradually increasing duration as functional capacity improves. 1 This approach is critical because standard upright exercise may worsen symptoms in post-COVID-19 patients with cardiac issues. 1 Pulmonary rehabilitation programs (8-12 weeks, 3 times weekly) demonstrated an average 84.3-meter improvement in 6-minute walk test distance and significant reduction in dyspnea scores. 3

Volume Management

• Salt loading: 5-10 grams (1-2 teaspoons) of table salt daily through liberalized sodium intake (avoid salt tablets to minimize nausea) 1
• Fluid loading: 3 liters of water or electrolyte-balanced fluid daily 1
• Elevate head of bed with 4-6 inch blocks during sleep 1
• Use waist-high support stockings 1

Pharmacological Management (Cardiac-Safe Options)

For Tachycardia and Palpitations

Exercise extreme caution with beta-blockers in patients with cardiac compromise. While low-dose beta-blockers (bisoprolol, metoprolol, nebivolol) or nondihydropyridine calcium-channel blockers (diltiazem, verapamil) may be used empirically for palpitations, beta-blockade can precipitate cardiogenic shock in patients with greater compromise of cardiac function. 1

Ivabradine is the safer alternative for patients with severe fatigue exacerbated by beta-blockers, showing improvement in heart rate and quality of life in POTS patients after one month. 1

For Orthostatic Intolerance

• Fludrocortisone: Up to 0.2 mg at night to increase blood volume (monitor for hypokalemia) 1
• Midodrine: 2.5-10 mg, first dose in morning before getting out of bed, last dose no later than 4 pm 1

For Chest Pain Without Ischemia

• NSAIDs: 1-2 week trial for pleuritic pain or costochondritis 1
• Low-dose colchicine: Add as needed for persistent inflammation 1
• Calcium-channel blockers, long-acting nitrates, or ranolazine: For suspected endothelial dysfunction 1

Corticosteroid Considerations

Use systemic corticosteroids in patients with myocarditis and concurrent COVID-19 pneumonia requiring supplemental oxygen. 1 For myocarditis with hemodynamic compromise, intravenous corticosteroids may be considered as this approach was associated with favorable prognosis. 1

Critical Monitoring Points

• Avoid dehydration triggers: alcohol, caffeine, large heavy meals, excessive heat exposure 1
• Monitor for barotrauma if using higher PEEP strategies in mechanically ventilated patients 1
• Assess for de-escalation of empiric antimicrobials daily 1
• Perform follow-up cardiac testing (ECG, echocardiogram, CMR) at 3-6 months, particularly with ongoing symptoms 1

Advanced Therapies

For refractory dyspnea despite optimization, consider hyperbaric oxygen therapy, which significantly improved global longitudinal strain (-17.8 to -20.2) in post-COVID-19 patients with subclinical left ventricular dysfunction. 4 Pulmonary consultation is essential for dyspnea unrelated to cardiovascular disease to guide further evaluation. 1