Public Health

Long COVID: Know the cardiac, pulmonary, musculoskeletal symptoms

Jennifer Lubell , Contributing News Writer

A multitude of cardiopulmonary and musculoskeletal symptoms can appear in patients with long COVID, often within a three-month window. Dealing with this complicated issue requires a team-based approach, according to Carlo Milani, MD, a physiatrist with the Hospital for Special Surgery in New York City.

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“Part of developing treatment paradigms for long COVID will come from reporting, understanding and recognizing when somebody's suffering with long COVID and then studying it to understand what the sources of all this are,” said Dr. Milani, who gave a presentation on the cardiopulmonary and musculoskeletal complications in long COVID at the 2022 AMA Interim Meeting.

About 10% to 30% of patients might experience long COVID after recovering from the initial acute infections. Health officials in the U.S. and U.K. define long COVID as sequelae that emerge between four and 12 weeks.

The more symptoms a patient has early on with COVID-19—and the more severe those symptoms are—the greater chance they will develop long COVID, said Dr. Milani, who is on Twitter @CarloMilaniMD. Specific to cardiopulmonary and musculoskeletal issues, “we see symptoms of fatigue, dyspnea, chest pain, cough, myocardial inflammation, palpitations, myalgias, and arthralgias,” he said.

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A study published in The Lancet on long-term cardiovascular outcomes in COVID-19 survivors among the unvaccinated found that the virus affects the cardiovascular system more strongly than the pulmonary or musculoskeletal systems, said Dr. Milani, an alternate delegate for the American Academy of Physical Medicine and Rehabilitation.

The 12-month risk of cardiovascular disease was much higher among COVID-19 survivors than in a similar control group of patients without COVID-19.

In another study, published in Nature Medicine, researchers examined estimates of risk with incident burden of prespecified cardiovascular outcomes among patients treated in the Department of Veterans Affairs. Investigators compared 150 patients with COVID-19 to about 5.5 million contemporary controls and 5.5 million historical controls.

“The big headline was that beyond 30 days, there's an increased risk of incident of cerebrovascular disorders, dysrhythmias, ischemic and nonischemic heart disease, pericarditis, myocarditis and heart failure, and thromboembolism,” said Dr. Milani, an AMA member.

The risks of this were evident regardless of age, race, sex or other cardiovascular risk factors such as obesity, hypertension, diabetes, chronic kidney disease and hyperlipidemia. “You were also at greater risk even if you had no cardiovascular disease prior to your infection,” he said.

Increased risk of myocarditis and pericarditis persisted, regardless of whether a patient was vaccinated or not.

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Long-term pulmonary complications of COVID represent a spectrum of diseases. The most common symptom is dyspnea, with some patients needing long-term ventilator or oxygen support, and fibrotic lung disease.

One study has shown that dyspnea can appear in up to two-thirds of patients within 100 days after infection. The need for supplemental oxygen due to persistent hypoxemia or the need for breathing support while sleeping is almost 7% in some patients at 60 days follow up, said Dr. Milani. Reduced diffusion capacity is the most reported physiologic impairment.

“That seems to be directly related to your severity of illness. If you were on a ventilator or required ICU level care, then you're at much greater risk of that,” he added.

Some survivors of COVID-19 have persistent restrictive pulmonary physiology at three to six months. This is similar to other studies of patients with acute respiratory distress syndrome, noted Dr. Milani.

Musculoskeletal complications are also common in patients with long COVID. Research shows that after three months, almost 90% of survivors have at least one symptom of long COVID, which commonly includes fatigue, joint or muscle pain. In addition, 70% of those patients had at least one rheumatologic or musculoskeletal complication, which could include conditions such as muscle wasting, neuropathy or reactive arthritis. After six months, about 60% of survivors still had at least one symptom and many of those were musculoskeletal or rheumatologic, said Dr. Milani.

“A better understanding of the underlying pathophysiologic process is going to be a big piece of understanding how to treat this going forward,” he concluded.

Read about the other highlights from the 2022 AMA Interim Meeting.