Johns Hopkins Medicine
Wendy Susan Post, M.D., M.S.
For people who have had COVID-19, lingering COVID-19 heart problems can complicate their recovery.
Some of the symptoms common in coronavirus “long-haulers,” such as palpitations, dizziness, chest pain and shortness of breath, may be due to heart problems — or, just from having been ill with COVID-19. How do you tell if your symptoms are heart-related, and what can you expect if they are?
Cardiologist Wendy Post, M.D., clarifies which post-coronavirus symptoms may point to a heart issue, when to call your doctor, and other facts all long-term COVID-19 survivors should know.
What are the possible heart issues after COVID-19?
COVID-19, the disease caused by the SARS-CoV-2 coronavirus, can damage heart muscle and affect heart function.
There are several reasons for this. The cells in the heart have angiotensin converting enzyme-2 (ACE-2) receptors where the coronavirus attaches before entering cells. Heart damage can also be due to high levels of inflammation circulating in the body. As the body’s immune system fights off the virus, the inflammatory process can damage some healthy tissues, including the heart.
Coronavirus infection also affects the inner surfaces of veins and arteries, which can cause blood vessel inflammation, damage to very small vessels and blood clots, all of which can compromise blood flow to the heart or other parts of the body. “Severe COVID-19 is a disease that affects endothelial cells, which form the lining of the blood vessels,” Post says.
Heart Rate and COVID-19
After you have had COVID-19, if you are experiencing a rapid heartbeat or palpitations you should contact your doctor. A temporary increase in heart rate can be caused by a lot of different things, including dehydration. Make sure you are drinking enough fluids, especially if you have a fever. Symptoms of a rapid or irregular heart rhythm may include:
- Feeling your heart beat rapidly or irregularly in your chest (palpitations)
- Feeling lightheaded or dizzy, especially upon standing
- Chest discomfort
What are the signs that I may have developed a heart problem after COVID-19?
“There are many symptoms reported in the post-COVID period, and there are multiple potential causes for these symptoms,” says Post.
“Severe fatigue is common after infection with the coronavirus, just as it is after any serious illness. Many people experience shortness of breath, chest pain or palpitations. Any of these problems could be related to the heart, but they could also be due to other factors, including the aftermath of being very ill, prolonged inactivity and spending weeks convalescing in bed,” she says.
POTS after COVID-19. People recovering from the coronavirus sometimes show symptoms of a condition known as POTS (postural orthostatic tachycardia syndrome). Researchers are exploring whether or not there is a link.
POTS isn’t directly a cardiac problem, but a neurologic one that affects the part of the nervous system that regulates heart rate and blood flow. The syndrome can cause rapid heartbeats when you stand up, which can lead to brain fog, fatigue, palpitations, lightheadedness and other symptoms.
Is a heart attack more likely after COVID-19?
That depends: Post says that “heart attack” has several different forms. A type 1 heart attack, caused by a blood clot blocking one of the heart’s arteries, is rare during or after COVID-19 infection.
“Type 2 heart attacks are more common with COVID-19,” she says. “This heart attack can be caused by increased stress on the heart, such as a fast heartbeat, low blood oxygen levels or anemia, because the heart muscle isn’t getting enough oxygen delivered in the blood in order do this extra work. We have seen this in people with acute coronavirus disease, but it is less common in those who have survived the illness.”
“Blood tests have shown that during COVID-19, some people have elevated levels of a substance called troponin in their blood, along with EKG changes and chest pain.” Elevated troponin levels are a sign of damaged heart tissue. Sometimes this is from a heart attack. This is less commonly seen after COVID-19.
“During acute COVID-19, elevated troponin levels with an abnormal EKG are linked to higher mortality, but not in patients with a normal EKG,” Post says.
What about heart problems in children after COVID-19?
In general, children who get sick with the coronavirus do not have serious problems as often as adults do. But a very rare complication of COVID-19 called multisystem inflammatory syndrome in children, or MIS-C, can cause serious heart damage, cardiogenic shock or death.
Children who survive MIS-C can be left with abnormal heart rhythms and stiffened heart muscle that prevents the heart from relaxing normally and beating properly. MIS-C has some similar characteristics to Kawasaki disease.
When should I see a doctor if I’m having heart symptoms after coronavirus?
|Symptom||When to call 911||When to call your doctor|
|Shortness of breath||
Shortness of Breath or Chest Pain After COVID-19: Are these signs of an emergency?
Shortness of Breath
“You want to consult a doctor if any of your symptoms are severe, especially shortness of breath,” Post says. She recommends using a commercially available O2 (oxygen) saturation monitor.
“Shortness of breath by itself is not always a sign of a serious problem, but if you have that symptom along with low O2 (below 92%), that is a reason to be concerned.” Sometimes people are short of breath with exertion after COVID-19 because they have been less active for a long time and need to gradually build their fitness level back up.
COVID-19 Chest Pain
What about lingering chest pain, another common post-COVID complaint? “Chest pain may be nothing serious, but if you are having severe chest pain, get help, especially if it is persistent or if you are also having nausea, shortness of breath or lightheadedness: These could be symptoms of a heart attack.”
“If you have chest pain when you inhale, you might have lung inflammation. Sudden, severe chest pain could be a blood clot in the lung (pulmonary embolism),” Post says.
Family doctor or cardiologist?
If your symptoms are not severe but you want to be checked out, Post says a cardiologist doesn’t need to be your first stop if you’ve never had heart problems before and are not at risk. “For nonemergency post-COVID-19 symptoms, your primary care practitioner can advise you,” she says.
Heart Failure and COVID-19
A diagnosis of heart failure after COVID-19 is rare. But if you have shortness of breath or leg swelling after COVID-19, you should contact your doctor, who may recommend evaluation by a cardiologist if tests indicate you are at risk.
A sign of heart failure is shortness of breath, but this has many other potential causes, including COVID-related pneumonia and other noncardiac causes. Symptoms of heart failure may include:
- Shortness of breath, especially with exertion
- Shortness of breath when lying down
- Leg swelling
- Frequent urination at night (Note: frequent urination at night in men is a common symptom of an enlarged prostate.)
Is heart damage caused by COVID-19 permanent?
Post says that if symptoms are due to a cardiac cause, recovery depends on the severity of injury. “Very few people have a severe heart attack, such as an acute myocardial infarction, or MI, due to COVID-19,” she says.
Still, heart imaging can reveal minor changes in the heart muscle of some COVID-19 survivors. Post notes that some studies on athletes recovering from the coronavirus have shown some scarring, but stresses that some of these studies did not compare these results with those who had not had COVID-19. How long these minor changes persist — and how they affect heart health — are not yet known. Experts are developing protocols and recommendations for which athletes should get cardiac testing before returning to play.
COVID-19 can also affect the strength of the heart pumping, Post says, but subtle abnormalities in heart pumping are not likely to cause people problems.
A person recovering from COVID-19 may benefit from physical therapy, breathing exercises, and most of all, time. Post advises anyone recovering from COVID-19 should expect a gradual course of recovery, and should not expect a rapid return to their normal activity levels.
Can having COVID-19 make an existing heart condition worse?
“A heart condition could be exacerbated by severe COVID, but not likely after mild or asymptomatic cases,” Post says. “But the effects of the coronavirus on preexisting heart disease are not yet known.”
Can heart problems show up long after COVID-19 recovery?
If you have had COVID-19, recovered and feel all right now, should you worry? Are heart problems likely to show up later on?
Post emphasizes that many of these questions do not have clear answers yet. SARS-CoV-2 was isolated in 2019, and the vast majority of COVID-19 survivors have only been recovering for several months. It is hard to know exactly how the disease will affect people’s hearts long term, and this is just one area of intense concern among researchers.
She mentions that the National Institutes of Health is working with dozens of academic medical institutions to track COVID-19 survivors’ health. Study groups, such as one called C4R, are consolidating patient data to help predict the long-term impact of the coronavirus on health and continuing care.
Research on Heart Problems After COVID-19
Research shows that there is still a lot to learn about lasting heart effects on people who have had COVID-19. In some cases, patients are left with signs of heart damage that may call for continued monitoring.
Post cites a German study in which cardiac MRIs were conducted on 100 people who had the coronavirus and survived. The researchers saw abnormal findings in 78 of these patients. Compared with those who had not had COVID-19, these patients showed evidence of scarring and inflammation of the heart muscle and its surrounding tissue (pericardium). However, this study was limited by the lack of an appropriate comparison group, and subsequent studies have found a much lower incidence of myocarditis in those who had a prior COVID-19 infection.
Another small study assessed 26 college athletes who had COVID-19 with mild symptoms or none at all. Cardiac MRI showed that these students had normal EKGs and normal levels of a substance called troponin, which when elevated can indicate heart problems. Four of them had heart muscle inflammation (myocarditis), and two of these had inflammation of the pericardium (pericarditis).
Post says these data have to be considered carefully, since the sample sizes are small, and the pre-COVID heart health of the participants wasn’t known.
But, she says, they show the need for more, larger, more detailed studies. “These test results have led to much discussion about appropriate testing and return-to-play guidelines for adult athletes in competitive sports,” Post says. “We need to know more about potential risks associated with post-COVID syndrome, which in most of these cases is asymptomatic.”