Cardiovascular Sequelae of Covid-19 Infection in Post-Acute Phase

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Soumya Patnaik Amar N Patnaik


The wide array of clinical manifestations of the ongoing COVID-19 pandemic due to the SARS-CoV-2 infection continues to be a big puzzle to the healthcare professionals. The picture is becoming complex with appearance of new strains and widespread vaccination against the viral infection. The acute cardiovascular manifestations are diverse; but have been fairly well-documented. But the mechanism behind the persistent symptoms like dyspnea, fatigue, chest pain and other symptoms in some of the survivors, weeks and months after the onset of initial infection are poorly understood. The post-acute and long-term cardiovascular impact of COVID-19 affection on heart and other systems is not fully clear. As the survivors after an acute episode are fast growing in number, managing them is emerging as a new public health concern.


A recent study on cardiovascular outcomes of COVID-19 in post-acute phase by Xie et al in a cohort of 153,760 survivors of COVID showed that these individuals are at substantial risk of CV disorders like thromboembolic problems, arrhythmias, ischemic and non-ischemic myocardial injury, pericarditis, myocarditis and heart failure irrespective of the intensity of the initial infection. Currently, defining cardiovascular risk and predicting the long-term consequences in COVID survivors are issues of priority for the researchers and clinicians alike. The cardiac MRI is emerging as a useful tool to evaluate the myocardial damage in post-acute phase of COVID infection. This review is an attempt to analyze the existing knowledge and bring out the potential gaps in the understanding of these challenging issues after acute phase of COVID is over.


Keywords: SARS-CoV-2, long-COVID, myocardial injury, heart failure, Covid-heart

Keywords: SARS-CoV-2, long-COVID, myocardial injury, heart failure, Covid-heart

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PATNAIK, Soumya; PATNAIK, Amar N. Cardiovascular Sequelae of Covid-19 Infection in Post-Acute Phase. Medical Research Archives, [S.l.], v. 10, n. 11, nov. 2022. ISSN 2375-1924. Available at: <>. Date accessed: 29 mar. 2023. doi:
Review Articles


1. Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med 2020; 3: 1504-1507

2. Stefanini GG, Chiarito M, Ferrante G, et al. Early detection of elevated cardiac biomarkers to optimize risk stratification in patients with COVID-19. Heart 2020; 106:1512-8

3. Imazio M, Klingel K, Kindermann I, et al. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis? Heart 2020; 106: 1127–31

4. Friedrich MG, Cooper LT. What we (don’t) know about myocardial injury after COVID-19. Eur Heart J 2021; 42:1879-82

5. The Task Force for the management of COVID-19 of the European Society of Cardiology. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-Epidemiology, pathophysiology, and diagnosis. Eur Heart J 2021; 43: 1033-1058

6. Bavishi C,Bonow RO, Trivedi V, et al. Acute myocardial injury in patients hospitalized with COVID-19 infection: a review. Prog Cardiovasc Dis 2020; 63: 682–689
7. Barda N,Dagan N, Cohen C,et al. Effectiveness of a third dose of the BNT162b2 mRNA COVID-19 vaccine for preventing severe outcomes in Israel: an observational study. Lancet 2021; 398: 2093-2100

8. Bularga A, Chapman AR, Mills NL. Mechanisms of myocardial injury in COVID-19. Clin Chem 2021; 67: 1044-1046

9. Patnaik S, Patnaik AN. Heart failure in COVID-19 pandemic: Challenging management issues. J Med Sci Res 2020; 8:112-118

10. Jabri A, Kalra A, Kumar A, et al. Incidence of stress cardiomyopathy during the Coronavirus disease 2019 Pandemic. JAMA Netw Open 2020; 3(7): e2014780.

11. Guo T, Fan Y, Chen M, et al. Cardiovascular implications of fatal outcomes of patients with Coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5:811–8.

12. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol 2020; 75:2352-2371

13. Lewnard JA, Hong VX, Patel MM,et al. Clinical outcomes associated with Omicron (B.1.1.529) variant and BA.1/BA.1.1 or BA.2 subvariant infection in southern California. medRxiv 2022.01.11.22269045

14. Real time-learning-network-IDSA Newsletter-Post-Covid Conditions:] accessed on 09-22-2022

15. Islam MF, Cotler J, Jason LA. Post-viral fatigue and COVID-19: lessons from the past epidemics. Fatigue Biomed Health Behav 2020; 8:61-69

16. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19. NICE guideline [NG188]. (18 December 2020).

17. WHO Document: WHO/2019-nCoV/Post_COVID-19_condition/ Clinical_case_definition/ 2021.1 - A clinical Case definition of post-COVID-19 condition by a Delphi Consensus, October,2021-14

18. Practice Guidelines Managing the long-term efforts of COVID -19: summary of NICE, SIGN, RCGP rapid guidelines. BMJ 2021; 372: n 136

19. Satterfield BA, Bhatt DL, Gersh BJ. Cardiac involvement in the long-term implications of COVID-19. Nature Reviews-Cardiology 2022; 19: 332-340
20. Carfì A, Bernabei R, Landi F. Persistent symptoms in patients after acute COVID-19. JAMA 2020; 324:603-05.

21. Halpin SJ, McIvor C, Whyatt G, et al. Post discharge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol 2021; 93:1013-22

22. Chopra V, Flanders SA, O'Malley M, et al. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19. Ann Intern Med 2021; 174(4):576-578

23. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID 19 in Wuhan China. JAMA Cardiol 2020; 5: 802-1

24. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of Covid-19. Nat Med 2022: 28; 583-590

25. Puntmann VO, Martin S, Shchendrygina A, et al. Long-term cardiac pathology in individuals with mild initial COVID-19 illness. Nat Med 2022; doi: 10.1038/s41591-022-02000-0. Online ahead of print

26. Rezel-Potts E, Douiri A, Sun X, Chowienczyk PJ, Shah AM, Gulliford MC. Cardiometabolic outcomes up to 12 months after COVID-19 infection. A matched cohort study in the UK. PLoS Med 2022; 19(7): e1004052.

27. Tereshchenko LG, Bisop A, Fischer-Campbell N, et al. Risk of cardiovascular events after Covid-19. Am J Cardiol 2022; 179: 102-109

28. Kotecha T, Knight DS, Razvi Y,et al. Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance. Eur Heart J 2021; 42(19):1866–78

29. Raman B, Bluemke DA, Luscher T, Neubauer S. Long COVID: Post-acute sequelae of COVID-19 with a cardiovascular focus. Eur Heart J 2022; 43: 1157–1172

30. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from Coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5(11):1265-73

31. Joy G, Artico J, Kurdi H, et al. Prospective case-control study of cardiovascular abnormalities 6 months following mild COVID-19 in healthcare workers. JACC Cardiovasc Imaging 2021; 14(11):2155-66

32. Rajpal S,Tong MS,Borchers , et al. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. JAMA Cardiol 2021; 6, 116–119

33. Daniels CJ, Rajpal S, Greenshields MS, et al. Prevalence of clinical and subclinical myocarditis in competitive athletes with recent SARS- CoV-2 infection: results from the Big Ten COVID-19 Cardiac Registry. JAMA Cardiol 2021; 6, 1078-1087

34. Martinez MW, Tucker AM, Bloom OJ, et al. Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening. JAMA Cardiol 2021; 6: 745-752

35. Udelson JE, Rowin EJ, Maron BJ. Return to play for athletes after COVID-19 infection: the fog begins to clear. JAMA Cardiol 2021; 6: 997-999

36. 36.Poppas A, Chung EH, Kovacs R. COVID-19 and the athlete: gaining ground but not yet at the finish. J Am Coll Cardiol 2021; 77:1368

37. Gluckman TJ, Bhave NM, Allen LA, et al. 2022 ACC expert consensus decision pathway on cardiovascular sequences of COVID-19 in adults: Myocarditis and other myocardial involvement, a post-acute sequelae of SARS-CoV-2 infection, and return to play. J Am Coll Cardiol 2022:79:1717-1756
38. Al-Aly Z, Xie Y, Bowe B. High-dimensional characterization of post-acute sequelae of COVID-19. Nature 2021; 594: 259-264

39. Tazare J, Walker AJ, Tomlinson L, et al. Rates of serious clinical outcomes in survivors of hospitalization with COVID-19: a descriptive cohort study within the OpenSAFELY platform. MedRxiv 2021. doi: 10.1101/2021.01.22.21250304

40. De Rosa S, Pascarella C, Basso C, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020; 41:2083

41. Mahfam MM, Spata E, Goldacre R, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020; 396:381-389

42. Cenko E, Badimon L, Bugiardini R, et al. Cardiovascular disease and COVID-19: a consensus paper from the ESC Working Group on Coronary Pathophysiology & Microcirculation, ESC Working Group on Thrombosis and the Association for Acute Cardiovascular Care (ACVC), in collaboration with the European Heart Rhythm Association (EHRA). Cardiovasc Res. 2021; 117(14):2705-2729

43. Ahmed AI, Saad JM, Han Y, et al. Coronary Microvascular Health in Patients with Prior COVID-19 Infection. JACC: Cardiovascular Imaging 2022; 79 (9_supplement) 1822.

44. Ayoubkhani D, Khunti K, Nafilyan V, et al. Post-COVID syndrome in individuals admitted to hospital with COVID-19: retrospective cohort study. BMJ 2021;372:n693

45. Garcia-Zamora S, Picco JM, Lepori AJ. et al. Abnormal echocardiographic findings after COVID-19 infection: a multicenter registry. Int J Cardiovasc Imaging 2022.

46. Ovrebotten T, Myhre P, Grimsmo J et al. Changes in cardiac structure and function from 3 to 12 months after hospitalization for COVID-19 Clin Cardiol 2022; 1-9

47. Moody WE, Liu B, Mahmoud-Elsayed HM,et al. Persisting adverse ventricular remodeling in COVID-19 survivors: a longitudinal echocardiographic study. J Am Soc Echocardiogr 2021;34:562–566

48. de Graaf M, Antoni M, Ter Kulie M,et al. Short-term out patient follow-up of COVID-19 patients: a multi-disciplinary approach. EClinical med 2021; 32: 100731

49. Evans RA, McAuley H, Harrison EM, et al. Physical, cognitive, and mental health impacts of COVID-19 after hospitalization (PHOP-COVID): a UK multicenter prospective cohort study. Lancet Respir Med 2021; 9: 1275-1287

50. Wellborn J, Karamnov S, Fields KG, Yeh T. Covid-19 increases the risk for the onset of atrial fibrillation in hospitalized patients. Sci Rep 2022; 12: 12014

51. Blitshteyn S, Whitelaw S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients. Immunol Res 2021; 69: 205-211

52. Lau ST, Yu WC, Mok NS, et al. Tachycardia amongst subjects recovering from severe acute respiratory syndrome (SARS). Int J Cardiol 2005; 100: 167-169

53. Jamal SM, Landers DB,HollenbergSM, et al.Prospective evaluation of Autonomic dysfunction in Post-Acute sequlaof Covid-19. J Am Coll Cardiol 2022;79:2325-2330

54. Long B, Brady WJ, Bridwell RE, Singh M, et al. Electrocardiographic manifestations of COVID-19. Am J Emerg Med 2021;41: 96-103

55. Zhou, M. et al. Cardiovascular sequalae in uncomplicated COVID-19 survivors. PLoS One 2021; 16: e0246732.

56. Anupama BK, Soumya A, Chaudhuri D. Prolonged QT interval in a patient with corona virus disease-2019: Beyond hydroxychloroquine and azithromycin.J Invest Med: High impact case reports 2021; 8: 1-7

57. Hosseini Z, Ghodsi S, Hezazi SF. Persistent Complete Heart Block in a patient with COVID 19 infection: a case report. SN Compr Clin Med 2022; 3: 259-262

58. Go AS, Reynolds K, Grace H, et al. COVID-19 and risk of VTE in ethnically diverse populations Chest 2021; 160: 1459-1470

59. Knight R, Walker V, Samantha I, et al. Association of COVID-19 with major arterial and venous thrombotic diseases: a population wide cohort study of 48 million adults in England and Wales. Circulation 2022; 146: 892-906

60. Morris SB. Schwart NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, CDC-Morbidity and Mortality weekly review: Weekly / October 9, 2020 / 69(40);1450–1456

61. Bastug A, Aslaner H, Bilir YA, et al. Multiple system inflammatory syndrome associated with SARS CoV 2 infection in an adult and an adolescent. Rheumatol Int 2021; 41:993-1008

62. Pillay J, Gaudet L, Wingert, et al. Incidence, risk factors, natural history, and hypothesized mechanisms of myocarditis and pericarditis following covid-19 vaccination: Living evidence syntheses and review. BMJ 2022; 13: 378: e069445

63. Barda N, Dagan N, Ben-Shlomo Y, et al. Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting. N Engl J Med 2021; 385(12):1078–90

64. Patone M, Mei XW, Handunnetthi L, et al. Risks of myocarditis, pericarditis, and cardiac arrhythmias associated with COVID-19 vaccination or SARS-CoV-2 infection. Nat Med 2021; 28: 410-422

65. Tenforde MW, Kim SS, Lindsell CJ, etalIVY Network InvestigatorsCDC COVID-19 Response TeamIVY Network Investigators. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network — United States, March-June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-8.
doi: 10.15585/mmwr.mm6930e1 pmid: 32730238

66. Greenhalgh T, Knight M, Court C, et al. Management of post-acute covid-19 in primary care. BMJ 2020; 370: m3026

67. Li P, Wu W, Zhang T, et al. Implications of cardiac markers in risk-stratification and management for COVID-19 patients. Crit Care 2021; 25: 158
68. Patterson BK, Guevara-Coto J, Yogendra R, et al. Immune-Based Prediction of COVID-19 Severity and Chronicity Decoded Using Machine Learning. Front Immunol 2021;12:700782

69. Swank Z, Senussi Y, Manickas Z, et al. Persistent circulating SARS-CoV-2 spike is associated with post-acute COVID-19 sequelae. Clin Infect Dis 2022; ciac722

70. Sanghvi SK, Schwarzman LS, Nazir NT. Cardiac MRI and Myocardial Injury in COVID-19: Diagnosis, Risk Stratification and Prognosis. Diagnostics (Basel) 2021; 11(1):130

71. Huang C, Huang L, Wang Y. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021; 397:220-232

72. Callen AL, Tanabe J, Ashesh A, et al. Evaluation of cerebrovascular reactivity and vessel-wall imaging in patients with prior COVID-19: a prospective case-control MRI study. Am J Roent 2022- ahead of print

73. Payne AB, Gilani Z, Godfred-Cato S, et al.; MIS-C Incidence Authorship Group. Incidence of multisystem inflammatory syndrome in children among US persons infected with SARS-CoV-2. JAMA Netw Open 2021; 4: e2116420.

74. Accessed on 09-22-2022