This is important because our readers are anesthetizing many post COVID pts
The American College of Cardiology (ACC) has issued a new expert consensus decision pathway for the evaluation and management of adults with cardiovascular consequences stemming from a COVID-19 infection. Over the past two years, numerous post-infection symptoms have been attributed to the effects of long COVID-19, also known by its official clinical designation as post-acute sequelae of SARS-CoV-2 infection (PASC). The ACC document discusses myocarditis and offers guidance for long COVID patients and on resumption of exercise and participation in sports after a COVID infection.
The clinical guidance “2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19: Myocarditis, Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) and Return to Play” was published today in the Journal of the American College of Cardiology.
“The best means to diagnose and treat myocarditis and long COVID following SARS-CoV-2 infection continues to evolve,” said Ty Gluckman, MD, MHA, co-chair of the expert consensus decision pathway and medical director of the Center for Cardiovascular Analytics, Research, and Data Science at Providence St. Joseph Health in Portland, Oregon. “This document attempts to provide key recommendations for how to evaluate and manage adults with these conditions, including guidance for safe return to play for both competitive and non-competitive athletes.”
Gluckman said the goal of the document is to provide guidance as physicians are trying to figure out how best to evaluate and manage these patients. As part of this document, Gluckman said they assembled a group of cardiac experts to create a framework to assist clinicians and to figure out the preferred ways to evaluate and managing patients presenting with symptoms that may track back to the cardiovascular system.
Overview of long COVID and its cardiovascular manifestations
Long COVID, or PASC, is a condition reported by 10-30% of infected patients. It is defined by a constellation of new, returning or persistent health problems experienced by patients four or more weeks after COVID-19 infection. The condition may manifest in widely disparate organ systems, and individuals can present with a range of symptoms that may be tracked in the cardiovascular system, Gluckman explained. The biggest symptoms of concern for cardiologists include myocarditis, tachycardia, exercise intolerance, chest pain, palpitations and shortness of breath.
“We recognize that often these individuals will present to their primary care clinicians seeking further evaluation and treatment, and many long COVID clinics have been created at medical centers across the United States,” Gluckman said, adding this is where most patients be be referred from for cardiac evaluations.
The writing committee has proposed two terms to better understand potential etiologies for those with cardiovascular symptoms:
• PASC-CVD, or PASC-Cardiovascular Disease, refers to a broad group of cardiovascular conditions (including myocarditis) that manifest at least four weeks after COVID-19 infection.
• PASC-CVS, or PASC-Cardiovascular Syndrome, includes a wide range of cardiovascular symptoms without objective evidence of cardiovascular disease following standard diagnostic testing.
The new guidelines suggest patients with long COVID and cardiovascular symptoms should undergo evaluation with laboratory tests, electrocardiograph (ECG), echocardiogram, ambulatory rhythm monitoring and/or additional pulmonary testing based on their clinical presentations. Cardiology consultation is recommended for abnormal test results, with additional evaluation based on the suspected clinical condition, especially myocarditis.
Myocarditis in long COVID PASC patients
Gluckman said myocardial and pericardial involvement is one of the biggest concerns post COVID so that was a primary focus in the document. “We do see cases of myocarditis as a rare manifestation after SARS-COVID-2 infection, These cases have been described well throughout the literature, since the pandemic began,” he said.
Myocarditis, or inflammation of the heart, is a condition defined by the presence of cardiac symptoms (chest pain, shortness of breath, palpitations), an elevated cardiac troponin (biomarker of cardiac injury), and abnormal electrocardiographic (ECG), cardiac imaging (echocardiogram, cardiac magnetic resonance imaging, or fluorodeoxy-glucose (FDG)-PET) and/or cardiac biopsy findings. Gluckman said very aggressive manifestations myocarditis can involve conduction heart block, cardiac shock and severe compromise of left ventricular ejection fraction.
“The time course for myocarditis can often develop weeks after their original infection, so it’s not inconsistent to have someone who presents weeks or a month plus after their original infection. And in fact, myocarditis is the underlying condition that is responsible for some symptoms of long COVID,” Gluckman explained. “That being said, I do want to reassure individuals that the vast majority of individuals with long COVID do not have myocarditis. But as part of the basic evaluation that we outlined from a cardiovascular standpoint, that may be done by a primary care clinician.”
Although rare, myocarditis with COVID-19 is more commonly seen in men. Because myocarditis is associated with a higher risk of cardiac complications, a proactive management plan should be in place to care for these individuals, the ACC said. For patients with mild or moderate forms of myocarditis, hospitalization is recommended to closely monitor for worsening symptoms, while undergoing follow-up testing and treatment. The consensus document says patients with severe myocarditis should ideally be hospitalized at centers with expertise in advanced heart failure, mechanical circulatory support and other advanced therapies.
Management of myocarditis caused by COVID vaccines
Myocarditis following COVID-19 mRNA vaccination is very rare, the ACC document stated, but a section was included for the management of these patients. As of May 22, 2021, the U.S. Vaccine Adverse Event Reporting System (VAERS) noted rates of 40.6 cases per million after the second vaccine dose among male individuals aged 12-29 years and 2.4 cases per million among male individuals over the age of 30. Corresponding rates in female individuals were 4.2 and 1 cases per million, respectively.
Although most cases of myocarditis following COVID-19 mRNA vaccination are mild, the consensus document suggests these patients should be diagnosed and treated similarly to those with myocarditis following a COVID-19 infection. The document also states that currently approved COVID-19 mRNA vaccines are highly effective, and the benefit-to-risk ratio is very favorable across all demographic groups.
The document includes a risk vs. benefits figure based on data from the Centers for Disease Control and Prevention (CDC). It states that, for every 1 million COVID-19 mRNA vaccinations in males 12-29, it is expected there will be about 39-47 more cases of myocarditis. However, on the benefits side of the scale, these vaccinations help prevent 560 fewer hospitalizations, 138 fewer ICU admissions and 6 fewer deaths.