Is it long COVID? Anxiety and fatigue five weeks after SARS-CoV-2 infection

A 62-year-old retired woman presents to you complaining of extreme fatigue, anxiety, a racing heart and difficulty sleeping.

Five weeks before her visit, she had experienced COVID-19. Her daughter had inadvertently brought it home from university and tested positive. Your patient and her husband tested positive two days later.

They both had a mild illness, with a sore throat and tiredness for four days. They isolated at home for the required eight days, although had not reported the illness to the Ministry of Health as they did not want to comply. They were angry with the Government’s management of the pandemic and the “political damage” caused. Your patient and her family had previously had the first, second and third (booster) doses of the Pfizer–BioNTech (Comirnaty) vaccine.

Her husband returned to his work as a builder after eight days of isolation. However, your patient had remained tired. She then started to become anxious about long COVID after she read about this “syndrome” in the paper. She was less able to sleep and became even more tired.

Over the last week, she had been aware that her heart was “racing”, particularly when in bed at night. She also noticed she was short of breath when she walked with her friends, although she had not done any exercise for four weeks after the SARS-CoV-2 infection.

She is usually well, although is always rather anxious and intermittently mildly depressed. She takes paroxetine 20mg daily. Her past history is of a cholecystectomy at age 55. She has three children, all in their twenties, who have left home. She is a non-smoker and drinks only a minimal amount of alcohol.

On examination, your patient is obviously stressed and anxious, with a blood pressure of 140/95mmHg. Her pulse is regular at 80 beats per minute, with normal heart sounds. Her venous pressure is not raised, and her chest is completely clear. Her abdomen is soft and normal, and she has no obvious neurological signs.

Fortunately, a friend recently sent you the 2022 American College of Cardiology consensus document on long COVID,¹ which you plan to use to help with your patient’s management. A resting electrocardiogram is performed.

1. What does the ECG show?

2. What is long COVID now called?

3. In simple terms, what is severe long COVID?

a. What is the more common presentation of long COVID?

4. What would be your initial management plan?

a. Why do a troponin and brain natriuretic peptide (BNP) test?

5. Does your patient have long COVID?

6. How will you try to help her become well once more?

Almost all organs can be damaged with a SARS-CoV-2 infection. This harm can be transient or leave significant residual damage

1. The ECG shows sinus rhythm, a normal axis and a rate of 73 beats per minute. It is normal.

2. Long COVID is now termed post-acute sequelae of SARS-CoV-2 infection, or PASC. It is defined as “a heterogeneous disorder without a universally accepted definition for its widely varying presentations. Patients with PASC have symptoms that present after SARS-CoV-2 infection, usually persisting for four to 12 weeks and beyond”.¹

From the cardiac perspective:¹

• PASC-cardiovascular disease (PASC-CVD) refers to known cardiovascular disease entities that can present four weeks or more after SARS-CoV-2 infection, including myopericarditis, myocardial ischaemia, non-ischaemic cardiomyopathy, microvascular dysfunction, thromboembolism, pulmonary vascular disease and arrythmias.
• PASC-cardiovascular syndrome (PASC-CVS) is a “heterogeneous disorder that includes widely ranging cardiovascular symptoms, without objective evidence of cardiovascular disease using standard diagnostic tests”.

3. Almost all organs can be damaged with a SARS-CoV-2 infection. This harm can be transient or leave significant residual damage, particularly in the unvaccinated patient. In the heart, lungs and other organs, extensive scar tissue, or damage from vascular occlusions or other inflammatory mechanisms, might leave these organs unable to properly function.

a. More commonly, in many patients after SARS-CoV-2 infection, there is no clear physical organ damage but an increase in mental health problems, including anxiety and depression, and a post-viral syndrome of lethargy and constitutional ill health. This appears to be similar to the post-infectious fatigue syndrome seen after other viral or bacterial illness. These symptoms are common and are now seen by all New Zealand clinicians. It is important to support the patient to recover and avoid a prolonged period of ill health.

4. You have already performed a careful clinical examination, which was normal, and an ECG, also normal. You arrange for a chest x-ray and some blood tests, most importantly troponin and N-terminal proBNP tests, as well as a full blood count, C-reactive protein, creatinine and electrolytes, liver and thyroid function tests, and a serum glucose level.

a. A troponin (T or I) test is the safe way to exclude (or confirm) myocarditis (inflammation of the myocytes). If the test is negative, this is not a case of myocarditis. A small rise in troponin might be from a myopericarditis, which is a more severe pericarditis, with inflammation of the pericardium and inflammation of the outer rim of the myocardium. A normal NT-proBNP excludes a significant strain of cardiac ventricular function.

5. The blood tests and chest x-ray are normal.

By definition, your patient does have long COVID – she has PASC-CVS (symptoms without objective evidence of disease). However, you are aware of the post-viral syndrome which causes similar symptoms – probably a mixture of a mild physical illness and some significant emotional ill health. It seems unlikely that any significant organ damage has occurred in your patient.

6. You adopt a reassuring, supportive and “expectant” management plan, with advice to your patient to slowly increase her exercise over several weeks and months. With several reviews in the next few weeks, she recovers both emotionally and physically, and returns to her normal self.

Details have been changed to protect patient confidentiality

Chris Ellis is a consultant cardiologist at The Heart Group and Mercy Hospital, Auckland