Post-COVID Symptoms and the Cardiovascular System Q&A
Gilbert Perry, MD, Vice Director for Clinical Services, Division of Cardiovascular Disease
Is there anything that can help alleviate muscle fatigue and heaviness during exercise?
Muscle aches are a very common symptom after COVID. A wide variety of problems can cause muscle aches and fatigue, including prolonged bed rest, inactivity, and severe inflammation during the early stages of COVID. Some patients may suffer muscle breakdown as a result of severe inflammation. Your doctor can do bloodwork to determine if there is ongoing, active muscle breakdown. Physical rehabilitation and regular exercise can help rebuild muscle loss and improve exercise capacity.
I had a normal cardiac MRI, but I still have episodes of tachycardia (heart rate over 100 beats per minute) and chest pain. Is this normal?
There are many causes of chest pain. If the MRI was normal and your troponin levels are normal, then heart injury due to COVID is likely not the cause of your chest pain. Your physician would need to get a careful description of the type of chest pain you are having to determine if you need additional testing for other causes of chest pain. A rapid heart rate at rest or with exertion is common in recovering or post-COVID patients referred to my cardiology clinic, but in most cases it is not due to a heart problem. Most of these patients have normal cardiac test results. Causes of rapid heart rate can include being out of shape (deconditioning) due to prolonged illness and too much bed rest. Some patients develop an abnormal rise in heart rate upon standing, a condition called postural orthostatic tachycardia syndrome (POTS). This is caused by an abnormality in the autonomic nervous system, which regulates blood flow back to the heart. If your heart rate is gradually coming down each time you walk or run, that’s a sign that you are getting better.
My heart races quickly after any exertion, and I tire quickly. How can a build my endurance back up?
I advise people not to try to do too much too soon. Some patients actually feel worse for a day or two after over-exerting themselves. I would advise mild levels of exercise that are within your comfort zone, such as walking, and doing that every day – even if it’s just for 5-10 minutes to start. Every week or two, increase the amount of exercise time until you can exercise comfortably for 30-45 minutes daily. After that, you can also increase the intensity of the exercise. If your heart races whenever you stand up, you can try recumbent (reclined) exercise machines, such as a rowing machine, or a semi-recumbent bicycle to see if you tolerate those better than upright exercise. Most of my patients report significant improvement after 6-12 weeks using this approach.
I have an elevated heart rate. What test can be performed to see how much damage has been done to my heart?
Most patients with an elevated heart rate who do not have other cardiopulmonary symptoms, such as chest pain or dyspnea (breathing trouble), do not have heart damage. Blood work (troponin levels test), an ECG, and an echocardiogram can identify patients who may have heart damage. Telemetry monitoring can identify patients with heart rhythm problems. Many post-COVID patients may experience a rapid heart rate due to inactivity or prolonged illness. This will get better with regular exercise as they recover. Other patients have a rapid heart rate when standing. This may be due to a disorder of the autonomic nervous system known as postural orthostatic tachycardia syndrome (POTS).
At what point should heart palpitations concern me after having COVID?
A telemetry monitor can record your heart rhythm and help determine if palpitations represent an abnormal heartbeat. Heart palpitations – feelings that your heart is pounding, fluttering, or beating irregularly – are most concerning in patients with known or suspected heart injury or who have a weak heart muscle. Many patients feel palpitations even when their heart rhythm is normal; in these cases, a normal telemetry study can be very reassuring.
What arrhythmias (irregular or abnormal heart rhythms) are you seeing post-COVID? How long before these start to subside, if at all?
The most common heart rhythm complaint I hear from patients is heart pounding or racing. When we put a monitor on these people, most of them do not have abnormal rhythms, but many do have faster-than-expected heart rates (sinus tachycardia). This can be due to a problem with the part of the nervous system that regulates heart rate, called the autonomic nervous system. In other patients who have been hospitalized and very ill, or inactive due to severe fatigue, the heart may race due to “deconditioning” (being out of shape). In these patients, the symptoms usually will improve gradually as they resume normal activities and start to exercise. Exercising in a recumbent (reclined) position and staying hydrated may help patients who have a heart rate increase and dizziness upon standing (a condition called postural orthostatic tachycardia syndrome, or POTS). In a small number of patients with evidence of heart injury, we may see abnormal beats from the heart’s main pumping chambers (premature ventricular contractions) or another type of arrhythmia called ventricular tachycardia. This can be a serious condition in people with heart injury, and it requires an evaluation by a cardiologist – especially before resuming vigorous exercise.
Exercise is suggested for treating “brain fog”, but minimal exertion causes my heart rate to spike into the 90-110 beats per minute range. Recommendations?
In general, exercise is thought to be good for brain function, and it also may help with anxiety or depression, both of which can affect thinking and concentration in some post-COVID patients. So, it isn’t unreasonable to try exercising for treating post-COVID “brain fog”. A heart rate of 90-110 beats per minute is not a concern as long as you otherwise feel well during exertion. Your doctor or a physical rehab specialist can help you create an exercise plan that suits you, including setting a heart rate range to expect during exercise. If you exercise regularly, you should see your heart rate during exertion come down over time.
How long after COVID recovery does one usually see changes in an ECG? Are there cardiac symptoms to watch for?
ECG changes can occur at various times after COVID, and they can come and go in the same patient over time. ECG changes don’t always mean heart damage. Heart damage is likely to start sometime during the first few weeks of having COVID. Chest pain, or shortness of breath not due to a lung problem, may indicate a higher risk of heart problems. In such cases, patients may benefit from further testing, especially if the symptoms continue.
How common is dizziness and loss of ear function among post-COVID patients?
Inner ear problems cause a type of dizziness called vertigo. In a survey of post-COVID patients, about one-third experienced earaches, and two-thirds had dizziness or vertigo. However, many conditions can cause dizziness. For example, if your blood pressure drops when you stand up, or if you get an abnormal heart rate upon standing, that can make you dizzy. Inner ear dizziness usually feels like a loss of balance or like the room is spinning, and you may feel nauseated, too. Dizziness due to heart rate or blood pressure changes can be documented by measuring your heart rate and blood pressure after lying down for 5 minutes and then standing up, or by doing a tilt table test.
My resting heart rate is usually around 55 beats per minute. Now it’s in the mid-40s, and it’s been 14 months since I had COVID. Should I see a specialist?
In general, a low resting heart rate is healthy. You might ask your primary care doctor to order an ECG test. You also might want to check your heart rate to see if it increases normally when you exert yourself. If the ECG shows that the rhythm is normal (sinus rhythm), and your heart rate increases with exercise, then you don’t need to be worried about it.
Why do some heart issues, such as blockages or enlargement, magically clear up?
The heart has the capacity to repair itself after injury. As the inflammation goes away, the heart often recovers. Medication can help in this process if the heart is weak.