Eleanor, a friend who is vaccinated and boosted, was always very careful about contacts with others. She met with a small group of friends for a holiday dinner, each of whom had also been vaccinated and boosted. A few days later one friend called to say that he had been diagnosed with Covid-19. She went to the local county health department and was tested and found to be negative. But a few days later fever and fatigue developed, the latter lasting about 10 days.
Afterwards she was fine but two months later, when getting out of bed to go to the bathroom, her heart rate jumped up to about 130 bpm. She laid back down but it persisted. Episodes like this occurred nearly every time she moved about and were very scary. On one occasion her heart rate got up to about 200 bpm. “I thought I was going to die.”
She saw her primary care physician at a time when her heart rate was normal. The physician did a history, exam, electrocardiogram and all was normal. She had no idea of what had happened and had no further suggestions. “If it recurs, come on back.” The symptoms did recur the next day and she went back to see the physician. This time she was sent for a cardiac echo and a CAT scan. Both were normal. [The history of recent Covid-19 should have suggested a Long Covid syndrome such as inappropriate tachycardia syndrome, postural orthostatic tachycardia syndrome (POTS) or some of the other arrhythmia syndromes associated with Long Covid. Unfortunately, relatively few doctors are aware.] The symptoms continued to occur and so she was finally referred to a cardiologist.
The cardiologist, also not familiar with Long Covid cardiac issues, was baffled by the symptoms and had her wear a Holter monitor (this device records the electrocardiogram continuously over a day or more) during the weekend. She returned on Monday and was told that she would hear the results within 24 hours. But despite frequent calls to the office, she didn’t hear for almost 10 days.
When finally called, it was a different doctor who said that on one occasion her heart rate had jumped up to 170 bpm and “this is very concerning.” She said “Yes, I agree. I know because I took my pulse then.” The cardiologist had no particular suggestions and was completely unaware of cardiac issues post Covid despite the fact that the patient had brought in references.
She is now seeing a specialist in Long Covid syndromes and who is quite competent in dealing with heart and vascular problems after Covid.
As outlined in my previous article, Long Covid occurs in 10 to 30% of individuals with mild Covid-19 infection. Some of these people develop various cardiovascular symptoms. I want to emphasize here that I am not referring to patients who have had severe Covid-19 with hospitalization and perhaps ventilator support. Instead, the focus is on individuals with mild Covid. As you will see, these individuals can develop various heart and blood vessel syndromes that can range from asymptomatic, to minor annoyances to quite severe, to death.
Heart damage is just one more aspect of Long Covid. It is known that the coronavirus can infect the cells of all three layers of the heart plus the outer lining of the heart, the pericardium. Coronavirus also infects the endothelial (lining) cells of the coronary arteries and other blood vessels. So there’s plenty of opportunity for the coronavirus to cause some level of damage to the heart and blood vessels. It also can attack the nervous system either directly or via autoantibodies.
It is a concern that this damage is occurring or can occur in young previously very healthy individuals. They are just the ones that typically have mild disease or asymptomatic infection. Fairly early in the pandemic there was a study of 26 college competitive athletes who had tested positive for Covid-19. Most of them were asymptomatic and none were hospitalized. Yet on MRI, 12 to 53 days following their initial diagnosis, 46% demonstrated evidence of myocarditis (inflammation of the heart muscle cells) or other cardiac injury. This was a wakeup call that even those who had mild disease could have some form of heart damage including those who were very healthy and young.
The question is — will the pandemic result in many individuals with damaged hearts, individuals that will need long term care?
My friend Eleanor in the opening story above has post exertion tachycardia or a related arrhythmia syndrome.
POTS has been known to be a rare syndrome since long before the pandemic. Most affected individuals, usually young women, report a “viral illness” that preceded onset. POTS can have associated fatigue and brain fog, memory difficulty and headaches, even nausea and vomiting. It is a form of “dysautonomia” that occurs in an estimated one to three million Americans. Dysautonomia refers to an imbalance in the autonomic nervous system, the sympathetic and parasympathetic systems that control heart rate, breathing, GI motility, blood pressure and other automatic functions of the body. Just what causes this imbalance is unclear.
Now POTS is being seen in increased numbers after mild Covid. Certainly not common but very disabling.
Inappropriate tachycardia syndromes including post exertion are being recognized with increasing regularity, sufficient that the term has been suggested as a distinct group of syndromes following Covid-19.
There is evidence that the vagus nerve, the long nerve that operates the parasympathetic system, is damaged by the coronavirus. This damage may be in part the cause of fatigue and other generalized symptoms. But there is also evidence that the tiny nerve endings throughout the body are damaged. Those that surround blood vessels can result in an inability of the smooth muscles around these vessels to contract normally and hence impacting blood pressure. It is likely that this damage is not directly from the virus. Rather, evidence points to the development of autoantibodies that damage nerve endings.
The patient’s history is the key to diagnosis of POTS but the confirmatory test is to lie flat for five minutes, then stand and compare the pulse before and after. If it rises by more than 30 bpm, the diagnosis is confirmed. In some individuals with POTS, the pulse will continue to rise even further over the next 5–10 minutes. Normally, the pulse should increase minimally after arising and then subside within a few minutes at most.
Pre-pandemic, doctors found that POTS could persist for long time frames or subside over weeks to months yet reoccur months later in some. It can be a lifetime of waxing and waning of varying severity. There is no cure. The usual treatment is to drink plenty of fluids, eat a salty diet, and wear full-length compression stockings. These can help but not fully alleviate the symptoms. It appears that post Covid POTS follows the same patterns.
One study of 20 patients, mostly female, with autonomic dysfunction after Covid-19 found (see image) that 6- eight months after diagnosis, 60% could not return to work, 25% could work with accommodations and the remainder were able to eventually return to work.
A series of 27 post Covid patients referred to the Mayo Clinic found a spectrum of autonomic dysfunction after Covid-19 including POTS, lightheadedness, fainting, headache on standing, excessive sweating and burning pains.
Inappropriate tachycardia syndromes including post exertion tachycardia and POTS are not common after Covid-19 but they occur enough that given some 80 million cases in America so far, there are or will be a vast number of individuals with inappropriate tachycardia syndromes and other autonomic disturbances seeking care. As noted above, most doctors including most cardiologists do not seem to be aware.
A major report of heart damage from the Veteran’s Affairs was published in early February, 2022. Epidemiologists looked at the long-term cardiovascular outcomes of individuals seen at any VA health setting during the first 10 ½ months of the pandemic. Using Veterans Affairs electronic health databases, the investigators found 153,760 individuals who had tested positive for COVID-19. Essentially none had received a vaccine as they were not yet available. There were also about 5.5 million during that time who never had a positive test who served as a concurrent control group. They also looked at another 5 ½ million veterans who visited the VA in the year before the pandemic — the historical control group.
The Covid positive individuals were evaluated for cardiovascular outcomes from 30 days after the positive test until 12 months later. They found a substantial number of individuals with cardiovascular disease such as irregularity of the heartbeat, damaged heart muscle, angina and heart attacks, heart failure, and various blood clotting problems, including strokes. The frequency of these diagnoses was compared to the two control groups to determine if they were occurring at the same or greater frequency, i.e., the controls represented the “expected” frequency among these veterans.
Covid-19 positive patients were divided into those never hospitalized for Covid, those hospitalized, and those requiring ICU care.
Those with severe Covid had many cases of persisting or new cardiovascular disorders. But what was more interesting were those with mild Covid who, although having many fewer episodes, the number of cases was very real. It boils down to about 20 more cases per thousand then would be expected based on the control groups.
The authors observe that Covid was “an equal opportunity offender” meaning that the risk was the same for old versus young, diabetes or not, obesity or not, and smoker or not.
It is important to note that these veterans do not represent a full cross section of Americans as they were mostly older white males.
So yes, the risk of cardiovascular disease for a non-hospitalized individual with mild Covid-19 is relatively low but can be a very serious problem for a substantial number of people. In this article I have noted damage to heart muscle from asymptomatic and mild Covid-19 in young healthy college students; autonomic dysfunction with inappropriate tachycardias and POTS after mild Covid; and more serious cardiovascular diseases also after mild Covid.
The total known number of COVID-19 infected people in United States is nearing 80 million. This implies a huge number of individuals with mild Covid will develop autonomic dysfunction like inappropriate tachycardias and multiple cardiovascular diseases during the first year after infection. This is sobering.
Please join me next time for a discussion of mental health/neuro-psychiatric syndromes after mild Covid-19.
