Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Understanding complications and outcomes of post-acute COVID-19 is essential to develop better management strategies to improve patient quality of life (QoL) and care and to expand the knowledge base of long-term effects of SARS-CoV-2 infection.

Research to date has included clinical studies, usually relying on patient recall, with potential selection bias, or lacking contemporary matched control participants. Disease classification is vulnerable to ascertainment bias, as hospitalized and community-based patients may differ in COVID-19 trajectory. The pathophysiology of post--COVID-19 syndrome (long COVID) has not been defined objectively, creating an information gap hindering development of management guidelines.

Study Synopsis and Perspective

One in eight adults hospitalized with COVID-19 subsequently develops myocarditis, often leading to impaired exercise capacity and health-related quality of life (HRQoL), according to an ongoing study looking at the clinical long-term effects of the SARS-CoV-2 virus.

The study also revealed evidence of persistent abnormalities in heart, lung, and kidney imaging, electrocardiography, and multisystem biomarkers after COVID-19 hospital discharge.

Importantly, said the researchers, it is the severity of a patient's COVID-19 condition, not their underlying health condition, that is most closely correlated to the severity of ongoing health issues after the patient leaves the hospital.

"We found that previously healthy patients, without any underlying health conditions, were suffering with severe health outcomes, including myocarditis, post hospitalization," principal investigator Colin Berry, MBChB, PhD, professor of cardiology and imaging, University of Glasgow, United Kingdom, said in a statement.

"The reasons for this are unclear, but it may be that a healthy person who is hospitalized with COVID-19 is likely to have a worse COVID infection than someone with underlying health conditions who is hospitalized," Berry said.

The study was published online May 23 in Nature Medicine.

The findings are based on 159 patients who are being followed after hospitalization for COVID-19 as part of the Scottish Cardiac Imaging in SARS CoV-2 (CISCO-19) study.

The mean age of the study participants was 55 years, 43% were women, and 47% had a history of cardiovascular disease (CVD) or treatment. Over an average post-discharge follow-up of 450 ± 88 days, 1 in 7 patients was readmitted to the hospital, and 2 in 3 required outpatient care.

Compared with a matched control group of patients without COVID-19, patients with COVID-19 showed evidence of cardiorenal inflammation, lung involvement, systemic inflammation, hemostatic pathway activation, and impairments in physical and psychologic function 28 to 60 days after discharge.

The likelihood of post--COVID-19 myocarditis (the primary outcome) was judged to be "very likely" in 13% of patients, "probable" in 41%, "unlikely" in 35%, and "not present" in 11%.

The etiology of myocarditis was predominantly SARS-COV-2 infection and less commonly myocardial ischemia due to coronary artery disease (CAD).

Myocardial scar was "surprisingly" common, affecting 1 in 5 patients with COVID-19, the researchers noted.

The fibrosis distribution in patients post--COVID-19 was "indicative of acute myocarditis, microvascular thrombosis, myocardial infarction, and preexisting scar with a nonischemic pattern. The prognostic implications of these findings should be clarified through longitudinal follow-up studies," the researchers said.

Almost one-quarter of the patients with COVID-19 were healthcare workers, and they had about a 3-fold higher likelihood of myocarditis, a finding that merits further investigation, the researchers said.

On univariate analysis, women had an increased likelihood of myocarditis, which, in turn, was linked to lower mental and physical well-being. This finding, they said, might provide a pathophysiologic basis for the physical limitations experienced by some women after severe COVID-19 that requires hospital care.

Myocarditis was associated with acute kidney injury during COVID-19 admission, with evidence of kidney inflammation 28 to 60 days after discharge.

"From a clinical perspective, cardiorenal injury was associated with persisting impairments in health-related quality of life, and poorer physical and psychological well-being during convalescence," the researchers said.

"Considering clinical translation, the results support a stratified management approach for post-COVID-19 patients early during convalescence," they added.

Chest abnormalities on computed tomography (CT) were also common 28 to 60 days after COVID-19 discharge.

The minimum patient-level fractional flow reserve on CT was lower in patients with COVID-19 than in 27 COVID-free control subjects, "consistent with flow-limiting [CAD]," the authors noted.

Magnetic resonance imaging (MRI) showed mild differences in ventricular function.

At baseline, circulating concentrations of C-reactive protein, ferritin, D-dimers, fibrinogen, factor VIII, and von Willebrand factor were higher in patients post-COVID than control participants, consistent with hemostatic pathway activation.

At 28 to 60 days after discharge, factor VIII concentrations remained high. Circulating concentrations of N-terminal pro B-type natriuretic peptide (NT-proBNP) were higher in patients with COVID-19 at baseline and 28 to 60 days after discharge.

Summing up, the researchers said their findings show that the illness trajectory of COVID-19 includes "persisting multisystem abnormalities that underlie impairments in health status, physical and psychological well-being during community convalescence."

The work was funded by the Scottish Government's Chief Scientist Office, and supported by the British Heart Foundation (BHF) as part of the University of Glasgow BHF Centre of Excellence. The authors have no relevant disclosures.

Clinical Implications

• The COVID-19 illness trajectory includes persistent cardiorenal inflammation, hemostatic pathway activation, and lung involvement.
• Implication of multisystem injury pathways mediating long COVID should help inform clinical guideline updates.
• Implications for the Healthcare Team: The findings support stratified management approaches for patients post--COVID-19 early during convalescence, including vaccination and pharmacologic and lifestyle interventions. Members of the healthcare team should utilize a team-based approach to provide patient education on effective COVID-19 mitigation strategies.

Earn Credit