ACC issues decision pathway for diagnosis, management of COVID-19-related cardiac injury
The American College of Cardiology has published its expert decision pathway for the etiology, diagnosis and management of myocarditis and long COVID after COVID-19 infection.
The document, published in the Journal of the American College of Cardiology, also provides a basis for a safe return-to-play for athletes after recovery from COVID-19.
“This expert consensus decision pathway provides a framework for evaluation and management of adults with cardiovascular sequelae following SARS-CoV-2 infection. Guidance provided is based on expert consensus, with multiple key takeaways,” Ty J. Gluckman, MD, FACC, FAHA, medical director of the Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health in Portland, Oregon, and co-chair of the writing committee, and colleagues wrote. “Importantly, it is intended to help clinicians understand not only when testing may be warranted, but also when it is not. Given that it reflects the current state of knowledge through early 2022, it is anticipated that recommendations will change over time as our understanding evolves.”
For this document, the writing committee aggregated existing knowledge on the CV impact of COVID-19 and provided information as it relates to myocarditis, long COVID and return-to-play for athletes.
“The best means to diagnose and treat myocarditis and long COVID following SARS-CoV-2 infection continues to evolve,” Gluckman said in a press release. “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 noncompetitive athletes.”
Myocardial injury
The committee wrote that COVID-19 infection- and vaccine-related cardiac injury, including myocarditis, has drawn significant attention during the pandemic. According to the document, although cases of severe myocarditis, from either infection or vaccination, remain rare, their existence has complicated immunization efforts.
The ACC report provides a decision pathway for the evaluation and management of patients with suspected myocarditis or myocardial involvement in both COVID-19 infection and vaccination. The pathway recommends that patients with suspected myocarditis or myocardial involvement receive an ECG, a cardiac troponin test and an echocardiogram.
Hospitalization is recommended for patients with mild to moderate COVID-19 infection- or vaccine-related myocarditis to monitor for worsening symptoms, follow-up testing and treatment, according to the press release.
“Randomized trials are also needed to better understand the preferred means to test and treat patients with myocarditis related both to SARS-CoV-2 infection and mRNA vaccination,” the committee wrote. “Although randomized trials in myocarditis have been challenging historically, the current pandemic has created unique opportunities for further investigation.”
Long COVID
In addition, the document contains the committee’s recommendations for the epidemiology, diagnosis and treatment of long COVID as it relates to the CV system.
The committee proposed the use of two new terms to differentiate post-acute sequelae of SARS-CoV-2 (PASC) symptoms that are either attributable to known CVD entities (PASC-CVD) or CV symptoms that are not explained by known CVD entities (PASC-CVS).
Based on the clinical presentation, laboratory tests, ECG, echocardiogram, ambulatory rhythm monitor and/or additional pulmonary testing may be considered for patients with long COVID with CV symptoms, according to the release. The committee recommended a cardiology consult with the finding of abnormal test results and additional evaluation based on the suspected clinical condition.
Due to the more complicated nature of PASC-CVS, the committee suggested that evaluation and management may be driven by the predominant CV 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,” Nicole M. Bhave, MD, FACC, cardiologist and echocardiographer at University of Michigan Health and co-chair of the consensus statement, said in the release. “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.”
Return-to-play for athletes
The committee also addressed questions surrounding the timing of return-to-play for athletes after COVID-19 infection.
Researchers observed low prevalence of clinical myocarditis among athletes after COVID-19 infection, without a rise in acute adverse cardiac events, according to the document.
The committee recommended further evaluation for athletes who continue to experience chest pain/tightness, dyspnea, palpitations, lightheadedness or syncope or those who may require hospitalization after COVID-19 infection and have suspected cardiac injury.
For athletes who are asymptomatic or have symptoms less suggestive of cardiac involvement such as fever, chills, lethargy or myalgias, the committee does not recommend additional cardiac testing.
In addition, for athletes with mild noncardiopulmonary symptoms, exercise training should be withheld until symptom resolution, according to the document.
Please see the full document for the ACC’s complete decision pathway recommendations.
“Beyond the indirect effects and undesirable consequences that COVID-19 has had on care delivery, it also remains to be seen how new variants and vaccine breakthrough infection will affect cardiovascular health,” the committee wrote. “Improved understanding of the associated near- and long-term consequences will be key in helping to improve clinical outcomes.”
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