A recent review was published online in the journal, Heart Rhythm in which the authors (Dr Raul Mitrani, Dr Nikita Dabas and Dr Jeffery Goldberger – with the University of Miami Miller School of Medicine’s Division of Cardiovascular Medicine) examined the varied cardiovascular injuries and complications that patients who have recovered from the acute Covid-19 infection may experience. The research was largely based on evidence from other viral infections or inflammatory injury to the heart.

It is unclear whether there will be post-COVID-19 cardiac syndrome’ and how best to manage patients recovering from COVID-19’s cardiac involvement [Image: Raxpixel].

“Our manuscript focused on potential mid- and long-term cardiovascular effects among patients who recovered from acute Covid-19 infection,” said lead author Dr Mitrani (Professor of Clinical Medicine and director of Clinical Cardiac Electrophysiology). “There is concern for patients having subtle or overt cardiovascular abnormalities in heart function or in cardiac rhythm disturbances, he continued.”

Similarly to other entities with acute cardiac injury, the authors believed there is likely to be a diverse response, depending on the mechanism of myocardial injury, severity of acute illness, therapy delivered, haemodynamic response, host factors, immune-mediated factors, and post recovery care and follow-up. “Based on other studies of patients with recovered myocarditis, type 2 MI, or other cardiac injury, it is expected that some patients will have sub-clinical and possibly overt cardiovascular abnormalities. Patients with ostensibly recovered cardiac function may still be at risk of coronary artery disease, atrial fibrillation or ventricular arrhythmias,” they posited.

“While current paradigms for treatment appropriately focus on acute recovery, it is unknown whether the treatment given during the acute illness may affect future cardiovascular pathology. Given the size of the pandemic, it is important to determine whether acute delivery of antifibrotic therapy, anti-inflammatory therapy, cell-based therapy or antiviral therapy affects long-term as well as short-term outcomes.”

SCREENING AND TRIALS

Although the optimal screening for patients after recovery from Covid-19 is unknown, the authors stressed the need for screening for residual cardiac involvement in the convalescent phase to establish the population burden of long-term cardiac disease contributed by Covid-19. “If a significant burden of disease is identified, trials of prophylactic therapies to prevent long-term complications may be appropriate. The type of testing and cost-effectiveness of screening tests for post-Covid-19 myocardial dysfunction/arrhythmias will need to be determined,” they said.

“We recommend standard electrocardiogram and echocardiogram recordings and possibly cardiac monitoring 2-6 months post recovery, with the recognition that even these tests may not detect subtle clinical abnormalities. Consideration should be given for advanced imaging when initial testing reveals abnormalities or as clinically indicated.”

Unfortunately, it is up to future studies to clarify whether there will be ‘postCovid-19 cardiac syndrome’ and how best to manage patients recovering from Covid-19’s cardiac involvement. “One of the key features of the Covid-19 illness is that it clearly has unique and novel aspects associated with it,” said co-author Dr Goldberger. “Because it is novel, we simply do not know what to expect. Our medical system is getting trained very quickly on the treatment for the acute illness, but we should also begin to focus on the longlasting effects.”

Warning against complacency the authors concluded: “Now is the time for action, to plan appropriate registries and clinical studies to assess the incident and significance of potential mid- and long-term cardiac abnormalities and dysrhythmias, with the hope and promise to mitigate these long-term sequelae.”