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Standard heart care is recommended for COVID-19 survivors left with cardiomyopathy and other cardiac conditions, though more answers are needed regarding how long they need to undergo special monitoring, and which groups are at particularly high risk.

The COVID-19 illness that had been characterized in early 2020 as a respiratory disease was soon linked to a variety of , including heart attack, myocarditis, and arrhythmia among infected people. The COVID-19 pandemic also had the indirect effect of disrupting healthcare access around the world for those with chronic conditions such as heart failure, potentially worsening outcomes for many patients.

Now, hospitals are back to resuming routine care, and patients with heart symptoms are encouraged to make their appointments.

"We urge our patients to seek care for heart failure and cardiomyopathy and do not delay care. We are able and willing to do routine care," said heart failure specialist Biykem Bozkurt, MD, PhD, of Baylor College of Medicine in Houston, in an interview.

"My personal observation is that healthcare institutions have developed strategies to provide continued care for non-COVID illness including cardiac disease," she said. "We have expanded and we have diversified our opportunities for encounters with patients, including both virtual and in-person appointments."

Clinicians are also grappling with the new practice of treating COVID survivors with lingering cardiac involvement, ranging from myocardial injury to thromboembolic events. These patients are said to suffer from long COVID -- also known as post-acute sequelae of SARS-CoV-2 infection (PASC) -- which was initially recognized by constitutional symptoms such as fatigue and brain fog persisting months after infection.

It turns out that long COVID can also manifest as cardiac symptoms. "We now recognize that postural orthostatic tachycardia syndrome, ongoing myocardial injury, and cardiomyopathy can be potential sequelae of COVID-19 infection. These [sequelae] of course vary according to the severity of the variants," Bozkurt said.

She said that researchers are still trying to figure out the prevalence and risk factors of PASC in pediatric, young adult, and older adult populations. Long COVID has been observed in COVID-19 survivors whether they had comorbidities or not, preexisting cardiac disease or not, and whether COVID was accompanied by severe symptoms, mild symptoms, or no symptoms at all.

In a based on data from the U.S. Department of Veterans Affairs, heart failure cases increased by 72% beyond the first 30 days after COVID infection when compared with controls who hadn't had COVID, representing nearly 12 more cases per 1,000 individuals.

Gregg Fonarow, MD, interim cardiology chief at University of California Los Angeles, highlighted the study's finding that COVID survivors who had been hospitalized were at greater risk, but even COVID patients who avoided hospitalization showed an excess risk of cardiomyopathy and heart failure.

For now, treatment for heart failure and cardiomyopathy after COVID is comparable to the treatment for heart failure patients who hadn't been infected, according to cardiologist Jim Januzzi, MD, of Massachusetts General Hospital and Harvard Medical School in Boston.

This generally consists of standard guideline-directed medical therapies (GDMT) based on the presence or absence of abnormal left ventricular ejection fraction.

One exception is that in the setting of COVID-related cardiogenic shock, some routine heart medications that have an effect on blood pressure may be held. But the patient should be initiated on GDMT when stabilized, according to Bozkurt.

"For those who may have had preexisting cardiac disease, we recommend they continue their cardiac medications and see their healthcare providers," she said.

"If someone who didn't have heart failure or cardiomyopathy develops heart failure subsequent to COVID-19, they will need to be treated in a multidisciplinary matter," she suggested. "First treat the COVID and acute cardiovascular and other complications, then PASC, individualizing the therapies and with close monitoring over follow-up."

Yet plenty of questions remain unanswered for now.

Given that it's unclear how long PASC can last, it is an open question whether people recovering from COVID-19 with evidence of cardiac injury will need to be monitored in the long run. Moreover, it's too soon to tell how much GDMT can be expected to help these patients.

After all, the mechanisms underlying the myriad clinical manifestations of COVID are themselves not well understood. Some believe them to be related to inflammation.

In the case of cardiomyopathy after COVID-19, the causes may be multifactorial. "Some cases represent acute viral myocarditis, some stress cardiomyopathy. Others may represent other types of myocardial injury or acute myocardial infarction. Further research is needed," Fonarow said.

He noted that cardiac biomarkers (e.g., cardiac troponins and natriuretic peptides) and cardiovascular imaging may help identify COVID patients at risk of cardiac involvement. "However, high-quality evidence to guide use of biomarkers or imaging for screening is lacking. Individuals with symptoms suggestive of cardiovascular disease should undergo clinician-guided evaluation," he said.

Regardless of a person's cardiovascular risk, cardiologists stressed COVID vaccination for eligible people.

"Vaccination is critical in preventing COVID infection as well as COVID sequelae such as cardiac complications. Benefits of the vaccination outweigh its risks for all age groups," Bozkurt said.

Januzzi and his colleagues "strongly encourage those who have not been vaccinated yet to re-consider receiving it, since this helps to reduce further risk for severe disease in the future, which may be catastrophic for someone already left impaired after one infection," he said.

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