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This anonymous blog by a doctor examines the link between Covid-19 and cardiovascular disease. The author calls for greater awareness amongst healthcare professionals and the public to reduce the risk of patients experiencing cardiovascular problems during and after Covid-19 infection. Since the beginning of the Covid-19 pandemic, we have known that the virus can affect the heart and cardiovascular system.[1] Covid is not primarily a respiratory disorder, it is a disease of the blood vessels. Recent statistics also suggest there has been an increase in excess deaths due to cardiovascular causes since the end of lockdown measures—but these deaths are not being linked to Covid-19 in official data. This area needs further research so that we can better understand the ways in which Covid is causing morbidity and mortality in the wider population. Research shows the link between Covid and cardiac events There have been many personal accounts of otherwise healthy people experiencing ongoing cardiac symptoms [2] due to Covid-19 infection. Now, over two years into the pandemic, we have significant research evidence establishing the link between Covid-19 and cardiovascular disease.[3] Multiple studies highlight an increased risk of stroke and heart attack after Covid,[4][5] and many show that the virus causes new onset cardiovascular issues in previously healthy individuals. Thrombosis and embolism can occur up to a year after infection,[4][7][8] even in people in their twenties, leading to significantly increased rates of cardiac events, angina, strokes and blockage of arteries to limbs. Despite this growing body of evidence, awareness is low among the public and the medical community that Covid-19 is a vascular disease. This means that patients are not always being assessed for potential heart problems, as they should be, when seeing a doctor or attending A&E with chest pain, palpitations or shortness of breath. Patients are being misinformed because of gaps in doctors’ knowledge As a result of this knowledge gap, there are also concerns that patients are being given inappropriate advice about exercise during and in the weeks following a Covid infection. Exercising with the virus can lead to cardiovascular issues developing or worsening, sometimes with devastating consequences. In addition to research about cardiovascular disease and Covid, we have a wealth of knowledge about exercise and myocarditis from sport scientists who have been studying cardiovascular disease in athletes for decades. A US study carried out in 2021 highlights that, “Emerging observational data coupled with widely publicized reports of athletes in competitive sports with reported Covid-19–associated cardiac pathology suggest that myocardial injury may occur in cases of Covid-19 that are asymptomatic and of mild severity.”[9] While the rates of cardiac involvement in athletes after Covid have been low, it is important to take a cautious approach. There is currently a lack of consistency in the advice patients are given about exercise and Covid, both in the acute stage of infection and afterwards in patients that develop Long Covid. Some people report having been actively advised by healthcare professionals to exercise following a recent Covid-19 infection, but this advice goes against what research tells us: As with any viral infection, exercising with an acute Covid infection, even if it is asymptomatic, increases the small risk of developing myocarditis—inflammation of the heart. If it occurs, myocarditis can cause sudden unexplained death in a small proportion of otherwise healthy adults. People with confirmed myocarditis should not undertake significant exertion for 3-6 months as there is a small but significant risk of sudden death.[10] Promoting a safe approach to Covid, work and exercise Part of the issue is the lack of guidance for GPs and other doctors dealing with both acute Covid patients and those with Long Covid. A rapid guideline on Managing the long term effects of COVID-19 published by the National Institute for Health and Care Excellence (NICE) in March 2022 stated that “in the absence of evidence relating to people with ongoing symptoms from Covid-19 [the panel] could not make specific recommendations,” although it also asserted that “the panel considered careful self-pacing of exercise to be an important element of self-management.”[11] But we now know enough to be able to provide some clear principles around safe exercise related to both acute Covid-19 infection and Long Covid. The World Health Organization living guideline on rehabilitation in Post Covid Condition recommends that in adults with Long Covid, “exertional desaturation and cardiac impairment following Covid-19 should be ruled out and managed before consideration of physical exercise training… Red flags for safe rehabilitation are those complications where commencing rehabilitation could cause an acute event or deterioration.”[12] World Physiotherapy also urges caution when it comes to exercise. In its briefing paper on safe rehabilitation in Long Covid, it states that, “It is critical to establish the reason or source of chest pain, dyspnoea, tachycardia, or hypoxia, to prevent harm and appropriately guide physical activity including exercise.”[13] It highlights that before physical activity is used as a rehabilitation intervention for people living with Long Covid, individuals should be screened for: post-exertional symptom exacerbation cardiac impairment exertional oxygen desaturation autonomic dysfunction and orthostatic intolerances.[13] Here are the key messages about Covid and safe exercise that we need to be getting across as widely as possible. Key messages for healthcare professionals The basic problem in Covid-19 is thrombotic vasculitis (inflammation of blood vessels) which leads to increased rates of serious cardiac and vascular complications in people of any age. Healthcare staff in accident and emergency, hospital medicine and general practice should know that cardiac complications of Covid-19 (angina, acute coronary events, arrhythmias and myocarditis) occur commonly after initial infection, even in young people, and can be present for a prolonged period after infection. Emergency department staff must be aware that myocarditis may occur during acute Covid-19, often caused directly by the virus, or in the weeks and months after infection, which is likely to be caused by an immune-mediated reaction.[14] Blood tests, including Troponin T and BNP should be taken, an ECG carried out and an urgent cardiac MRI should be arranged.[15] Key messages for the public and employers As with any viral infection, if you have Covid-19 you should rest during the first days of infection, when symptomatic. You should then follow a gradual approach to exertion following infection as recommended by the Faculty of Sport and Exercise Medicine UK’s Graduated Return to Play guidance following Covid-19 infection. It can be helpful to use a wearable tech device such as a heart rate and heart rate variability watch. You should also go by how you feel and not push through fatigue. If you have new and persistent chest pain in the days, weeks and months after Covid-19, you should not be undertaking exercise until you have had it investigated by a doctor. This advice also needs to be applied to returning to physically strenuous work following Covid; it’s vital to consider the cardiovascular aspects of Covid before staff can return to ‘heavy work’. To provide clear guidance for employers, the Society of Occupational Medicine recently published a position paper on Long Covid and return to work. The paper pulls together current evidence on how to return to work safely and sustainably after Covid-19. It collates practices from occupational health services around the world, and a range of medical specialists contributed lists of investigations, red flags and reasons for referral, and guidance on best practice for activity. A key theme through the document is the need for early intervention to prevent cardiovascular damage. Although exercise and exertion are part of many people’s daily routine, just pushing through Covid and Long Covid symptoms to maintain your routine is a dangerous approach. It’s better to miss your jog for a few weeks than risk long-term damage to your cardiovascular system. References 1 Eunjung Cha A. Young and middle-aged people, barely sick with covid-19, are dying of strokes. Washington Post, 25 April 2020 2 Dolgin E. COVID’s cardiac connection. Nature. 9 June 2021 3 Part 3: Graham Lloyd-Jones, The anatomy of COVID-19. Oro-Systemic Health Symposium 2022. 12 April 2022 4 Xie Y, Xu E, Bowe B et al. Long-term Cardiovascular Outcomes of COVID-19. Nature Medicine. 2022:28;583-90 5 Al-Aly Z, Bowe B, Xie Y. Outcomes of SARS-CoV2 Reinfection (preprint). 17 June 2022 6 Basu-Ray I, Almaddah N, Adeboye A et al. Cardiac Manifestations Of Coronavirus (COVID-19). StatPearls. 2 May 2022 7 Katsoularis I, Fonseca-Rodríguez O, Farrington P et al. Risks of deep vein thrombosis, pulmonary embolism, and bleeding after COVID-19: nationwide self-controlled cases series and matched cohort study. BMJ. 6 April 2022 8 Raman B, Bluemke DA, Lüscher TF et al. Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus. Eur Heart J. 2022:43(11);1157–72 9 Kim JH , Levine BD , Phelan D , et al. Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play. JAMA Cardiol. 2021:6;219–27 10 Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Majeed A, et al. Returning to physical activity after COVID-19. BMJ. 8 January 2021 11 National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19. 1 March 2022 12 World Health Organization. Clinical management of COVID-19: Living guideline, 15 September 2022 13 World Physiotherapy. Briefing paper 9 - Safe rehabilitation approaches for people living with Long Covid: Physical activity and exercise, 14 July 2021 14 Raman B, Bluemke DA, Lüscher TF et al. Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus. Eur Heart J. 2022:43(11);1157–72 15 Lampejo T, Durkin SM, Bhatt N, Guttmann O. Acute myocarditis: aetiology, diagnosis and management. Clinical Medicine. 2021:21(5);e505–10