SAN ANTONIO – New guidance by physical medicine experts shows cardiovascular symptoms associated with long COVID are widespread and could overwhelm the system if nothing is done.
Texas is the state with the second-highest number of long COVID cases, with more than 2 million.
That statistic is according to the American Academy of Physical Medicine and Rehabilitation (AAPM&R), which has already released consensus guidance on several long COVID symptoms, including fatigue, breathing discomfort, and cognitive symptoms.
“Upwards of 30% of people who are infected with COVID will go on to develop long-term problems,” said AAPM&R President-Elect Dr. Steven Flanagan, who is also the Rehabilitation Medicine Department Chair at New York University Langone Health.
That 30% translates to upwards of 27 million Americans.
“These are people who can’t get back to work, can’t fulfill their roles as family members. It really impacts them and is a disability,” Flanagan said.
On Tuesday, the organization released new guidance on cardiovascular symptoms.
“We know that they’re common. Myocardial injury has been reported in more than 40% of individuals. Acute heart failure in a third of patients that have been hospitalized for COVID, heart rhythm disturbances persistent in up to 20% of individuals, and ongoing inflammation has been reported up to three months after infection, in up to 60%,” said Dr. Jonathan Whiteson, the lead author on the Cardiovascular Complications Guidance Statement.
Dr. Whiteson is also the vice chair for Rusk Rehabilitation Clinical Operations and medical director of cardiac rehabilitation at New York University Langone Health.
He said the public and medical professionals must understand that this is not just happening to people who had a severe COVID-19 infection.
“We are seeing many people who had mild disease, were never hospitalized in the acute phase, developed cardiovascular disorders. Up to 4% of individuals who had mild disease have had a stroke or myocardial infarction in the post-acute stage,” Whiteson said.
Whiteson said the guidance statement on cardiovascular symptoms due to long COVID has three parts. He called the first part a wake-up call.
“A call to action for patients, for clinicians, health care providers, for health care systems, for insurance companies, for government agencies, for researchers. This is novel. We need to understand it. We need to get ahead of the game,” he said. “We cannot wait five years, 10 years to find out that these projections are absolutely spot on.”
Those projections are that many people who have never had cardiovascular disease before will develop it. Whiteson said that includes younger generations.
“We’re not seeing it yet, but we’re projecting a much younger generation could have more significant cardiovascular disease because of COVID infection and long-haul disease,” he said.
That’s where the second part of the statement comes in: guidance for healthcare providers on how to spot and treat long COVID cardiovascular disorders.
“For physicians not to misconstrue or underestimate what these symptoms may be -- so taking a detailed history, recognizing the symptoms of potential cardiovascular disease, including chest pain, shortness of breath, dizziness, palpitations. They may represent cardiac disease, even in the absence of other cardiac risk factors,” Whiteson said.
The main recommendation in that section is to treat every patient individually, not strictly relying on timeframes set in stone.
“An individual approach. We typically recommend activity for people with cardiovascular disease, but we have to be very cautious in individuals who have long COVID because they may have symptom exacerbation due to increasing activity and exercise,” Whiteson explained.
The last piece of the guidance statement addressed health care inequities for minorities and underserved communities.
“We know that in cardiovascular disease, there are already inequity issues with not only minorities’ access to care, but even with differences in sex for referral for rehabilitation of cardiac issues,” said guidance statement co-author Dr. Alba Azola.
Dr. Azola is also an assistant professor of Physical Medicine and Rehabilitation at Johns Hopkins Medicine and co-director of the Physical Medicine and Rehabilitation Post-Acute Covid Team Clinic.
She said the pandemic exacerbated these inequities, especially in immigrant populations.
“After hospitalization, these patients do not have access to rehabilitative needs. They don’t have access to equipment that they need, putting them at higher risk of developing disabilities and accessing needed care in order to recover from long COVID and cardiovascular issues related to long COVID,” Azola said.
Dr. Flanagan said, “There’s a bill in Congress now to help fund clinics, particularly in those areas that are serving underserved populations.”
He’s hopeful it will pass but said money isn’t the only thing that will fix the problem.
Whiteson added that education is necessary. He said most people with cardiovascular issues need rehab, typically from doctors of physical medicine and rehabilitation.
However, those referrals, or lack thereof, are causing inequity.
“The rates of referral for cardiac rehab, in general, are very poor. Only 20% to 30% of all who qualify for and should be getting cardiac rehab are actually referred, through,” Whiteson said. “The lowest rates of referral are in older African American women.”
He hopes spreading awareness will teach providers when they need to refer patients for cardiac rehab and encourage them to follow through.
“If they qualify for cardiac rehabilitation, if they have low pumping function of the heart or heart failure, if they’ve had a heart attack, then refer to the appropriate rehabilitation, which would be cardiac rehabilitation,” Whiteson explained.
Whiteston said providers who suspect something is off should run lab tests for blood counts, electrolytes, and other tests surrounding cardiac function and cardiac muscle damage.
“And undergoing the correct testing, which may include things like EKGs, ECHOs, looking at the chambers of the heart, stress tests, which look to see how the heart is at rest and then under physiological stress,” he added.
The recommendation to the public is to see a doctor when there’s any symptom that seems abnormal. They also maintain that lifestyle factors are important to not contribute to the problem. They suggest avoiding smoking, eating correctly, staying at the optimum weight, blood pressure control, blood cholesterol and blood sugar control, and exercising.
Flanagan said their recommendations seem to be getting through to people, even at the highest levels.
“About a year ago, we published a call to action to the Biden Administration and the Congress to really address this public health concern. We wanted to make sure there were going to be resources for clinics that are going to be treating these patients, ensure that there was equal access across the board, as well as making sure there were resources for research,” Flanagan said.
He said the Biden administration responded positively with a memorandum on actions they plan to take or are already taking.
There are about 40 long COVID clinics in the nation dedicated solely to treating long-haul patients.
Two of those are in San Antonio -- one run by University Health and the other by UT Health San Antonio. KSAT has interviewed the clinic director, Dr. Monica Verduzco-Gutierrez, who said the need is immense.
Her clinics have treated hundreds of patients, and University Health confirmed to KSAT on Wednesday that the waiting lists for the long COVID clinics are still between three and six months long.
“Nationally, we’re trying to get our legislators to pass types of bills that will support more long COVID clinics. There’s also only so many doctors we have that can treat this,” Verduzco-Gutierrez said.
She is one of the many practitioners working hand in hand with the AAPM&R to tend to patients worried about their prolonged and debilitating symptoms.
One of the public’s many questions is about how insurance companies are reacting to these needs.
“Insurance companies have been realizing that this is something new and have been supportive of a multidisciplinary approach, different physicians evaluating patients from different perspectives, developing a treatment plan,” Whiteson said.
He said Medicare typically sets the tone, and the current tone is promising.
“Medicare has approved cardiac and pulmonary rehabilitation even outside of the typical qualifying diagnoses, and many of the private insurances usually follow suit,” Whiteson said.
This new cardiovascular symptom guidance is packed full of useful information, but in the big picture, it boils down to a simple yet strong warning: inaction now will likely lead to a health disaster down the line.
The AAPM&R is already working on more guidance reports for other long COVID effects on pediatrics, neurology, autonomic dysfunction, and mental health.