ACC issues clinical guidance on cardiovascular consequences of COVID-19
Consensus document provides a framework for understanding, evaluating,
and managing some of the key cardiovascular sequelae of COVID-19

Date:
March 16, 2022
Source:
American College of Cardiology
Summary:
The American College of Cardiology has issued an expert consensus
decision pathway for the evaluation and management of adults
with key cardiovascular consequences of COVID-19. The document
discusses myocarditis and other types of myocardial involvement,
patient-centered approaches for long COVID and guidance on
resumption of exercise following COVID-19.



FULL STORY ==========================================================================
The American College of Cardiology has issued an expert consensus
decision pathway for the evaluation and management of adults with
key cardiovascular consequences of COVID-19. The document discusses
myocarditis and other types of myocardial involvement, patient-centered approaches for long COVID and guidance on resumption of exercise following COVID-19. The clinical guidance 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. "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." Myocarditis 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) and/or cardiac biopsy findings.

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. 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. Patients with severe myocarditis should ideally be
hospitalized at centers with expertise in advanced heart failure,
mechanical circulatory support and other advanced therapies.

Myocarditis following COVID-19 mRNA vaccination is also rare. As of
May 22, 2021, the U.S. Vaccine Adverse Event Reporting System 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 aged >30 years.

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, it should be diagnosed and treated similarly to myocarditis following COVID-19 infection. Currently approved COVID-19 mRNA vaccines are highly effective, and the benefit-to-risk
ratio is very favorable across all demographic groups evaluated thus far.



==========================================================================
Long COVID Post-acute sequelae of SARS-CoV-2 infection (PASC), commonly referred to as long COVID, is a condition reported by up to 10-30% of
infected individuals. It is defined by a constellation of new, returning
or persistent health problems experienced by individuals four or more
weeks after COVID-19 infection. While individuals with this condition
may experience wide-ranging symptoms, tachycardia, exercise intolerance,
chest pain and shortness of breath represent some of the symptoms that
draw increased attention to the cardiovascular system.

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.

In general, patients with long COVID and cardiovascular symptoms should
undergo evaluation with laboratory tests, ECG, echocardiogram, ambulatory rhythm monitor and/or additional pulmonary testing based on the clinical presentation.

Cardiology consultation is recommended for abnormal test results, with additional evaluation based on the suspected clinical condition (e.g., myocarditis).

Because multiple factors likely underlie PASC-CVS, evaluation
and management may be best driven by the predominant cardiovascular
symptom(s). For those with tachycardia and exercise intolerance, increased bedrest and/or a decline in physical activity may trigger cardiovascular deconditioning with progressive worsening of symptoms.



========================================================================== "There appears to be a 'downward spiral' for long COVID patients. Fatigue
and decreased exercise capacity lead to diminished activity and bedrest,
in turn leading to worsening symptoms and decreased quality of life," said Nicole Bhave, MD, co-chair of the expert consensus decision pathway. "The writing committee recommends a basic cardiopulmonary evaluation performed upfront to determine if further specialty care and formalized medical
therapy is needed for these patients." For PASC-CVS patients with
tachycardia and exercise intolerance, upright exercise (walking or
jogging) should be replaced with recumbent or semi- recumbent exercise
(rowing, swimming or cycling) to avoid worsening fatigue.

Exercise intensity and duration should be low initially, with gradual
increases in exercise duration over time. Transition back to upright
exercise can be done as one's symptoms improve. Additional interventions (increased salt and fluid intake, elevation of the head during sleep,
support stockings) and pharmacological treatments (beta-blockers) should
be considered on a case-by- case basis.

Return to Play Observation of cardiac injury among some patients
hospitalized with COVID-19, coupled with uncertainty around cardiovascular sequelae after mild illness, fueled early apprehension regarding the
safety of competitive sports for athletes recovering from COVID-19
infection. Subsequent data from large registries have demonstrated
an overall low prevalence of clinical myocarditis, without a rise in
the rate of adverse cardiac events. Based on this, updated guidance is
provided with a practical, evidence-based framework to guide resumption
of athletics and intense exercise training.

For athletes recovering from COVID-19 with ongoing cardiopulmonary
symptoms (chest pain, shortness of breath, palpitations, lightheadedness)
or those requiring hospitalization with increased suspicion for cardiac involvement, further evaluation with triad testing -- an ECG, measurement
of cardiac troponin and an echocardiogram -- should be performed. For
those with abnormal test results, further evaluation with cardiac magnetic resonance imaging (cardiac MRI) should be considered. Individuals
diagnosed with clinical myocarditis should abstain from exercise for
three to six months.

Cardiac testing is not recommended for asymptomatic individuals following COVID-19 infection. Individuals should abstain from training for three
days to ensure that symptoms do not develop. For those with mild or
moderate non- cardiopulmonary symptoms (fever, lethargy, muscle aches), training may resume after symptom resolution. For those with remote
infection (? three months) without ongoing cardiopulmonary symptoms,
a gradual increase in exercise is recommended without the need for
cardiac testing.

Based on the low prevalence of myocarditis observed in competitive
athletes with COVID-19, the authors note that these recommendations can
be reasonably applied to high-school athletes (aged ?14 years) along with
adult recreational exercise enthusiasts. Future study is needed, however,
to better understand how long cardiac abnormalities persist following
COVID-19 infection and the role of exercise training in long COVID.

The 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 will be discussed in a session at the American College of Cardiology's 71st Annual Scientific Session on April 3 at
4:30 p.m. ET.


========================================================================== Story Source: Materials provided by American_College_of_Cardiology. Note: Content may be edited for style and length.


========================================================================== Journal Reference:
1. Ty J. Gluckman, Nicole M. Bhave, Larry A. Allen, Eugene H. Chung,
Erica
S. Spatz, Enrico Ammirati, Aaron L. Baggish, Biykem Bozkurt,
William K.

Cornwell, Kimberly G. Harmon, Jonathan H. Kim, Anuradha Lala,
Benjamin D.

Levine, Matthew W. Martinez, Oyere Onuma, Dermot Phelan,
Valentina O.

Puntmann, Saurabh Rajpal, Pam R. Taub, Amanda K. Verma. 2022 ACC
Expert Consensus Decision Pathway on Cardiovascular Sequelae of
COVID-19 in Adults: Myocarditis and Other Myocardial Involvement,
Post-Acute Sequelae of SARS-CoV-2 Infection, and Return to
Play. Journal of the American College of Cardiology, 2022; DOI:
10.1016/j.jacc.2022.02.003 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2022/03/220316145752.htm

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