This is how cases of myocarditis due to COVID-19 should be treated, according to the American College of Cardiology

The first concern of science when the new SARS-CoV-2 coronavirus appeared was to find treatments to prevent severe conditions and deaths, which were caused by airway conditions. But soon after a growing number of patients became aware of different symptoms that were associated with COVID-19 and what, months after the pandemic began, was called prolonged COVID or long COVID.

More and more medical reports have warned how SARS-CoV-2 affects and even develops cardiovascular problems in people, especially those who have suffered the disease moderately or severely.

With the aim of guiding physicians, the American College of Cardiology (ACC) this week issued an expert consensus decision pathway for the evaluation and management of adults with cardiovascular consequences by COVID-19. The paper discusses myocarditis and other types of myocardial involvement, patient-centered approaches to prolonged COVID, and guidance on resuming exercise after illness. The clinical guideline was published in the Journal of the American College of Cardiology.

“The best means to diagnose and treat myocarditis and prolonged COVID after SARS-CoV-2 infection continue to evolve,” said Dr. Ty Gluckman, co-chair of the expert consensus decision pathway. “This document attempts to provide key recommendations on how to evaluate and manage adults with these conditions, including guidance for a safe return to play for both competitive and non-competitive athletes,” he explained.

In the document, the expert committee warned that “for some patients infected with SARS-CoV-2, cardiac symptoms (e.g. chest pain, shortness of breath, fatigue and palpitations) persist and last months after the initial illness. Laboratory and imaging tests of myocardial injury and involvement have also been observed in symptomatic and asymptomatic individuals, as well as after receiving the COVID-19 mRNA vaccine″, although the latter cases are considered isolated. “For physicians who treat these people, there are a growing number of questions related to the evaluation and management of these conditions, as well as the safe resumption of physical activity,” they stressed when arguing the need to issue this guidance.

The committee also clarified that the guidance “focuses on conditions that doctors may have difficulty diagnosing and managing,” such as myocarditis and post-acute sequelae of COVID-19, or prolonged COVID, (PASC), while “providing guidance on returning to the game (RTP)” for athletes and people who regularly engage in intense physical activity. The recommendations are aimed at the general population, but warned that “individualized approaches may be needed for specific populations, such as pregnant women, people with congenital heart disease in adults, people with pre-existing heart failure.” While there are other cardiovascular sequelae of COVID-19, such as thrombosis, this clinical orientation focused specifically on myocarditis.

Myocarditis, or inflammation of the heart, is a condition defined by the presence of heart symptoms such as chest pain, shortness of breath, palpitations, elevated cardiac troponin (biomarker of heart injury) and abnormal electrocardiography (ECG), cardiac imaging (echocardiogram, MRI) cardiac) and/or abnormal findings in cardiac biopsies.

The post-acute sequelae of SARS-CoV-2 infection (PASC), commonly known as prolonged COVID, is a condition reported by up to 10 to 30% of infected people. It is defined by a constellation of new, recurrent, or persistent health problems that people experience four or more weeks after COVID-19 infection. While people with this condition may experience a wide variety of symptoms, tachycardia, exercise intolerance, chest pain, and shortness of breath represent some of the symptoms that draw the most attention to the cardiovascular system.

The drafting committee proposed two terms to better understand the possible etiologies (origin of the disease) of people with cardiovascular symptoms: PASC-CVD, (PASC-Cardiovascular Disease), refers to a broad group of cardiovascular conditions (including myocarditis) that manifest at least four weeks after COVID-19 infection. Also, PASC-CVS, (PASC-Cardiovascular Syndrome), includes a wide range of cardiovascular symptoms without objective evidence of cardiovascular disease following standard diagnostic tests.

In its recommendations, the ACC warned that in general, patients with prolonged COVID and cardiovascular symptoms should be evaluated with laboratory tests, ECG (electrocardiogram), echocardiogram, ambulatory rhythm monitor and/or additional lung tests based on clinical presentation. “Consultation with cardiology is recommended if test results are abnormal, with additional evaluation based on suspected clinical condition” such as myocarditis.

“For those with tachycardia and exercise intolerance, increased bed rest and/or decreased physical activity can trigger cardiovascular deterioration with progressive worsening of symptoms,” he said. “There seems to be a 'downward spiral' for long-term COVID patients. Fatigue and decreased exercise capacity lead to decreased activity and bed rest, which in turn leads to a worsening of symptoms and a decrease in quality of life,” said physician Nicole Bhave, co-chair of the expert consensus decision pathway of the ACC. “The drafting committee recommends a basic cardiopulmonary evaluation conducted in advance to determine whether these patients need more specialized care and formal medical therapy,” he explained.

“The drafting committee proposes a multi-parameter approach to help guide decision-making. However, this is limited by the paucity of evidence on how best to diagnose and manage myocarditis and other forms of myocardial involvement with COVID-19,” the expert group admitted.

In addition, the experts recommended the “use of cardiac troponin (cTn) as the biomarker for the evaluation of patients with a possible diagnosis of acute myocardial infarction (AMI). When the suspicion of cardiac involvement is low, further cardiac tests are generally not recommended. Conversely, when suspected cardiac involvement is moderate or high, initial tests should generally consist of an electrocardiogram (ECG), cTn measurement (preferably by a high-sensitivity test), and an echocardiogram (transthoracic or point-of-care ultrasound). Because hospitalized patients with high cTn face a higher risk of adverse outcomes, stricter monitoring is generally warranted for possible deterioration.”

“In those with suspected myocardial involvement, CMR (magnetic resonance imaging) is recommended if the patient is hemodynamically stable. In symptomatic patients, CMR is the most sensitive method to rule out pre-existing ischemia and cardiomyopathies,” he recalled.

At all times faced with cardiac involvement, the group of experts urged the adoption of “a multidisciplinary approach in the evaluation of the majority of patients with PASC (prolonged COVID). Primary care physicians are often the first point of contact for these patients and help supervise and coordinate care with other specialists, including pulmonologists, cardiologists, neurologists, rheumatologists, psychiatrists, and infectious disease experts. Within this framework, a basic cardiopulmonary evaluation can usually be performed in advance to determine the need for specialized care.”

A reasonable initial approach by the general practitioner for people with cardiovascular symptoms includes: “1) basic laboratory tests (e.g. complete blood count, basic metabolic panel, cTn (biomarker of heart disease), C-reactive protein); 2) an ECG; 3) an echocardiogram; 4) an ambulatory rhythm monitor; 5) chest imaging (X-ray and/or CT); and/or 6) lung function tests”, he explained.

It also recommended “the cardiology consultation for those with: 1) abnormal heart test results; 2) known cardiovascular disease with new or worsening symptoms or signs (e.g. worsening of dyspnea in a patient with known heart failure); 3) documented heart complications during SARS-CoV-2 infection; and/or 4) persistent cardiopulmonary symptoms that are not otherwise explained.

“As part of a PASC evaluation, cardiologists should conduct a thorough history and physical examination, reviewing all relevant tests to help determine the likelihood of PASC-CVD,” he added. The committee recalled that “previously unrecognized heart disease can become clinically evident only in the context of acute illness.”

If myocarditis, pericarditis or other myocardial involvement is suspected, “additional evaluation should be carried out” such as those mentioned above and also “additional tests may be required depending on the clinical presentation (e.g. CT pulmonary angiography — computed tomography — for suspected pulmonary embolism) . Ultimately, for those with persistent symptoms but without PASC-CVD, an additional evaluation should be performed for PASC-CVS, dictated by: 1) the most prominent symptoms; 2) the baseline characteristics of the patient,” he stressed.

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