Cardiovascular Considerations in the Management of People with Suspected Long COVID 2023 Quinn et al

Abstract
Approximately 15% of adult Canadians with SARS-CoV-2 infection develop lingering symptoms beyond 12 weeks post-acute infection, known as post-COVID condition or long COVID. Some of the commonly reported long COVID cardiovascular symptoms include fatigue, shortness of breath, chest pain, and palpitations. Suspected long-term cardiovascular complications of SARS-CoV-2 infection may present as a constellation of symptoms that can be challenging for clinicians to diagnose and treat. When assessing patients with these symptoms, clinicians need to keep in mind Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), post-exertional malaise and post-exertional symptom exacerbation (PEM/PESE), cardiac dysautonomia such as Inappropriate Sinus Tachycardia (IST), and Postural Orthostatic Tachycardia Syndrome (POTS), and occasionally Mast Cell Activation Syndrome (MCAS).

This paper summarizes the globally evolving evidence around management of cardiac sequelae of long COVID. In addition, this review includes a Canadian perspective, consisting of a panel of expert opinions from experienced clinicians across Canada who have been involved in management of long COVID. The objective of this review is to offer some practical guidance to cardiologists and generalist clinicians regarding diagnostic and treatment approaches for adult patients with suspected long COVID who continue to experience unexplained cardiac symptoms.

Open access, https://www.onlinecjc.ca/article/S0828-282X(23)00303-3/fulltext

 

Haven't read this (have only skimmed it)

Article talks about screening for ME, PEM/PESE, advising that people rest/pace.


Definitions of specific conditions associated with long COVID.



Terms


Definitions / Diagnostic Criteria

Post exertion symptom exacerbation (PESE)/ Post-exertional malaise (PEM)

Characterized by worsening symptoms following physical or mental exertion, typically 12−48 h after activity and lasting days or (rarely) weeks. It is thought to involve an abnormal response following physical, cognitive, emotional, or orthostatic exertion, that would not have caused a problem before illness. With PEM/PESE, everyday activities that require mild effort can result in deteriorating physical and mental stamina, plus exacerbation of other symptoms. 47,6,67

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

A disabling clinical condition characterized by unexplained and persistent post exertional fatigue accompanied by a variety of symptoms related to cognitive, immunological, endocrinological, and autonomic dysfunction that can be diagnosed using the Canadian Consensus Criteria.68

Dysautonomia with cardiac manifestations

Malfunction of cardiovascular hemostasis regulated by the autonomic nervous system including Postural orthostatic tachycardia syndrome (POTS) and inappropriate sinus tachycardia (IST).69

Mast Cell Activation Syndrome (MCAS)

Characterized by typical clinical symptoms of flushing, hives, abdominal pain, diarrhea, paresthesias, and cognitive dysfunction, a substantial increase in serum tryptase level during an attack over the people's baseline tryptase, and a response of the symptoms to drugs targeting mast cells, mediator production, and/or mediator effects.70

 

I hope this article gets some traction with the intended audience.

It would be quite a positive step to have cardiologists on board. I don't know where this specialty is now as concerns ME. From personal experience decades ago, the small sample I encountered were quite disdainful.

 

It would be ideal if the transition in cardiologist thinking went something along the lines of —

"POTS is due to anxiety, including to simple things like standing up. Yes of course it's very fatiguing to have your heart constantly beating too fast. You should try to relax — also exercise is good for your heart and reduces anxiety you know."

-->

"Yes, the research is indicating that in some people there is a major deficit in energy production. The cells lining your blood vessels need energy to transmit the right signals to control their diameter. They're busy all the time making adjustments, particularly when we try to stand up from lying. This explains why many people have problems with fatigue and trouble standing.

Yes, we also now recognise that some people seem to just have the fast heart rate without much in the way of fatigue. Similarly some people are very fatigued and do have real trouble standing or sitting, but don't have the fast heart rate - they nearly all show a reduction in blood flow to the brain. We wonder if the fast heart rate might be a compensation to help the brain.

We think that if we can fix the problem with the energy production, that may fix the problem with people's blood vessels. Yes, we wonder if it may be an immune problem after a virus. It's possible this understanding may ultimately be able to prevent a lot of cardiovascular disease in people without fatigue. We're all very excited."

(Or whatever the explanation might be...)

 

There's a professional driver to be seen to be up-to-date or even ahead of the curve. As per usual social interactions, and by definition, this will be led by those who lead and teach. They and their fast-followers will cause an exponential function. I'd like to think that with the visibility of LC, we're now on an exponential curve with this understanding, although it's still the relatively flat part.

So in the happier corollary to "How did you go bankrupt? Two ways. Gradually, then suddenly." I can imagine a time in the not too distant future where "PEM/PESE" is simply widely accepted and is a specific part of the systematic enquiry*. It will likely be rapidly forgotten that this understanding was ever not the case.

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* Fatigue/malaise/lethargy/sleeping pattern are in eg constitutional symptoms. Exercise intolerance, palpitations, dizziness, loss of consciousness are in cardiovascular. There are relevant GI/GU/neuro symptoms etc. It just needs to be wrapped up with the right label around symptom increase to help guide the enquirer to the right observation and conclusion. Then there's a chance of helpful investigations and advice instead of gaslighting.