Chest pain after COVID-19 is among the concerning symptoms cardiologists are seeing, even as hospitalizations from the latest surge of COVID-19 cases recede.

Many recover initially from COVID-19 only to suffer weeks later from sometimes confounding symptoms that can affect all parts of the body. These individuals are the victims of long COVID, defined by the CDC as conditions patients experience four or more weeks after recovering from a COVID-19 infection.

Long COVID patients, or “long haulers,” battle symptoms that include chest pain, chronic fatigue, brain fog, shortness of breath, nerve problems, anxiety and depression, joint and muscle pain, and more.

UCHealth Today spoke with Dr. Natasha Altman, an advanced heart failure and transplant cardiology specialist with the Heart Failure Clinic at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Altman provides heart care for long COVID patients at the Post-COVID Clinic.

What are the most common symptoms you see in long COVID patients?

“The most common are chest pain, abnormally high heart rates, heart palpitations, shortness of breath, and difficulty doing the same exercises people were doing prior to having COVID,” Altman said.

Do you have a sense of the prevalence of long COVID?

profile shot of Dr. Natasha Altman, who talks about chest pain after COVID, among other symptoms of long COVID.
Dr. Natasha Altman provides care for long COVID patients with heart-related symptoms through the UCHealth Post-COVID Clinic.

“It is hard to estimate an overall prevalence in the era of the omicron variant,” Altman said. She said she sees five to six patients a week with a variety of post-COVID cardiac symptoms.

Does everyone with cardiac-related post-COVID issues have long COVID?

No. “COVID in patients with underlying heart disease is a known risk factor for complications,” Altman said. “These patients are at a higher risk of hospitalization, persistent illness and potentially death.” Altman added that people with a preexisting heart condition – heart failure and coronary artery disease, for example – generally have “a rough course” of recovery from COVID-19 and can be at greater risk for lung disease, blood clots and heart attacks.

Given that prospect, it’s vital for all people with any condition that heightens the high risk of complications from COVID to get vaccinated, Altman said.

Are you seeing patients who had mild to moderate COVID symptoms but show signs of long COVID?

Yes. “I have seen patients with very mild symptoms who weeks later started to develop chest pain, heart palpitations and difficulty breathing with exertion,” Altman said. “Some of these are people in their 20s and 30s who were perfectly healthy before COVID – mountain bikers and hikers who are now completely debilitated. These are the patients who can really benefit from seeing us in the multidisciplinary clinic. We can help to determine how much of the problem is heart- and lung-related, how much is deconditioning, how much is related to other potential issues. We try to piece it all together.”

Altman emphasized that younger people who are healthy are at lower risk of developing severe complications after COVID. “But we don’t how many of those folks and which ones are going to develop long-term symptoms,” she said. Vaccination, while not 100% effective, offers further protection against those uncertainties. Simply put, “Trying to avoid infection overall is preferable,” Altman said.

What has been the biggest challenge in helping patients with long COVID?

“It’s younger people who are completely exhausted after a minimal amount of exertion,” Altman said. A simple walk or five minutes on an exercise bike can leave people fatigued, short of breath and complaining of chest pain. “They are just completely wiped out, and that takes a long time to get better,” Altman added.

There are no shortcuts to helping patients with the problem. “We first make sure that we rule out any other underlying causes of their symptoms,” Altman said. “For example, we want to ensure that they don’t have inflammation of their heart, that their lungs are working well, and that they have no heart rhythm problems.”

If patients clear those tests, a difficult path sometimes lies before them. “They may have a persistent disability that takes a long time to get through,” Altman said. “I do have a number of patients who continue to struggle with that. It’s an uphill battle, made easier by working with a group of focused specialists like what we have assembled in the Post-COVID clinic at the University of Colorado Hospital.”

How can you help these chronically fatigued long COVID patients?

The multidisciplinary approach of the UCHealth Post-COVID Clinic is key to addressing chronic fatigue, as well as the array of other long COVID health issues, Altman said. For chronically fatigued patients, she works with specialists from physical therapy, physical medicine and rehabilitation, pulmonary rehabilitation and others, depending on each patient’s specific symptoms and complaints.

“The problem isn’t cardiac-specific,” she said. “It’s kind of a whole-body problem.”

A “consensus guidance statement” co-authored by Dr. William Niehaus, assistant professor of Physical Medicine and Rehabilitation at CU (and a provider in the UCHealth Post-COVID Clinic) underscores her point. Niehaus and his colleagues maintain that treating fatigue in long COVID requires addressing problems like inadequate sleep and nutrition; infectious and autoimmune diseases; and heart, lung and nerve disorders. They also recommend developing strategies to help patients return to activity gradually; conserve their energy; eat healthy foods; stay hydrated; and follow, if necessary, a regimen of medications and herbal and vitamin supplements.

Can long COVID patients help themselves through chronic fatigue?

Yes. Altman recommends staying active and exercising – but within boundaries. A good way to start is with recumbent biking and rowing, which helps to exercise the heart while reducing strain on the joints and muscles.

“Start out with very low-intensity exercise and resistance,” Altman said. “If you’re wiped out after five minutes, try two and slowly increase the time and resistance that you can tolerate.” She added that it’s a mistake for chronically fatigued patients to believe that they can simply push their way through it.

“People tend to exercise hard, then crash and have a huge setback,” Altman said. “Know your limitations and recognize those warning signs of when you are going to crash.”

It’s also important to stay hydrated with three to four liters a day of fluid (unless you have heart failure) while avoiding alcohol and caffeine and modestly increasing salt intake (unless you have high blood pressure).

What is myocarditis and is it connected with long COVID?

Myocarditis is inflammation of the heart muscle, or myocardium. It has many causes, but one is infection from viruses, including influenza, adenovirus (those responsible for colds, bronchitis, pneumonia and other illnesses) and SARS-CoV-2, which causes COVID-19. In severe cases, myocarditis can lead to heart failure and irregular heart rhythms.

Altman noted that the heart has receptors — ACE2 (angiotensin-converting enzyme 2) – to which the SARS-CoV-2 protein binds. “That may be an easier way for the virus to get into the heart muscle,” Altman said.

However, Altman said it is “rare” for COVID-19 patients to develop myocarditis, a conclusion supported by CDC research. It’s even rarer to see myocarditis in patients post-COVID, although it occurs occasionally. “We aren’t entirely sure why it happens,” she said. Altman is also the clinical principal investigator of a study examining the effects of the SARS-COV-2 virus on the hearts of critically ill COVID-19 patients. She added that she has done a number of cardiac MRIs, the “gold standard” for diagnosing myocarditis and has found the instances of it “rather low” in COVID-19 patients.

I also see something called POTS associated with long COVID. What is that?

POTS is short for postural orthostatic tachycardia syndrome, a mouthful for a condition that causes a variety of symptoms – changes in blood pressure and heart rate, lightheadedness, brain fog and fainting, among others – when a person stands up after lying down. The symptoms of POTS are similar to those of orthostatic intolerance, the difference being that the key symptom of POTS is a rapidly increased heart rate when a person stands up. Orthostatic intolerance generally causes blood pressure to drop during the transition to standing.

Altman said some long COVID patients do not have POTS “per se,” but do suffer from some of its symptoms, particularly an elevated heart rate when they stand up. More broadly, she said COVID-19 seems sometimes to disrupt the autonomic nervous system – the one that governs bodily functions like heart rate and blood pressure.

Are there ways to help with POTS symptoms?

Yes. It’s important that patients get plenty of fluids to increase their blood volume, Altman said, and avoid alcohol and caffeine, which dehydrate. These steps help to prevent large shifts in blood when a person stands up after lying down. Patients can help themselves with low-intensity, recumbent exercise, gradually increased over time. Altman said she also recommends compression garments, which can help to redistribute blood flow and lower heart rate.

What are some of the lessons learned about diagnosing and treating long COVID?

One major lesson: long COVID is consistently inconsistent. “It’s not predictable who is going to have long COVID. We’ve seen patients across the board,” Altman said. “We’ve also seen very different symptoms and presentations and learned to develop patient-specific treatment regimens.”

It follows that she and her colleagues no longer see long haul COVID as a single entity, Altman added. A patient with chronic fatigue will need different services than one with, say, abnormal heart rhythms. That highlights again the benefits of a multidisciplinary clinic and approach to care.

“We think about patients in the big picture,” Altman said. “We have gotten good at sorting out each patient’s symptoms and then developing a personalized plan based on our findings.”

Is more research on long COVID and cardiac-related symptoms, such as chest pain after COVID, underway?

Yes. An important one in which Altman is involved is a large National Institutes of Health study of long COVID called RECOVER. Among other efforts, RECOVER aims to recruit 17,000 patients across the United States to study not only long COVID patients but also those who recovered without long COVID and healthy controls. University of Colorado Anschutz Medical Campus is part of a consortium with the University of Utah, Intermountain Healthcare, University of New Mexico and Denver Health and Hospitals involved in the initiative.

Finally, when should I be concerned about post-COVID symptoms, such as chest pain?

An increase in heart rate in and of itself is not “horribly concerning,” Altman said. “But if you have any persistent problems like chest pain, shortness of breath, or feeling faint, those need to be checked out.”

Editor’s Note: During the pandemic, the Colorado Times Recorder will occasionally post articles, like this one, from UCHealth Today, which is published by UCHeatlh, the hospital associated with the University of Colorado School of Medicine. Our goal is to provide as many people as possible with accurate information about the virus and related topics.