ACC Issues Expert Guidance for Cardiovascular Sequelae After SARS-CoV-2 Infection

Senior man praying in ward. Male patient suffering from coronavirus is lying on stretcher. He is in hospital during pandemic.
The American College of Cardiology has published guidelines for managing adult patients with cardiovascular sequelae after COVID-19 infection.

The American College of Cardiology (ACC) has developed an Expert Consensus Decision Pathway (ECDP) for evaluating and managing adults with cardiovascular sequelae following SARS-CoV-2 infection, as published in the Journal of the American College of Cardiology.

The ECDP addresses frequently asked questions regarding the care of adults aged 18 years and older with cardiac symptoms such as chest pain, dyspnea, palpitations, and syncope after SARS-CoV-2 infection. It is intended to provide practical guidance in the absence of robust clinical trial data.

The recommendations from the ACC’s Solution Set Oversight Committee are limited to common cardiovascular sequelae in adult patients and are aimed at a broad, unselected population. The guidance focuses on 3 overall topics—myocarditis and other myocardial involvement; postacute sequelae of SARS-CoV-2 infection (PASC); and return to play among athletes.

Myocarditis and Other Myocardial Involvement

The definition and approach for diagnosing patients with myocarditis following SARS-CoV-2 infection is evolving based on advances in diagnostic testing such as cardiac magnetic resonance imaging (CMR) and improved understanding of the immunopathogenesis. The committee defined myocarditis as: cardiac symptoms (eg, chest pain, dyspnea, palpitations, syncope); an elevated cardiac troponin (cTn) level; and abnormal electrocardiographic, echocardiographic, CMR, and histopathologic findings on biopsy or postmortem evaluation in the absence of flow-limiting coronary artery disease.

In cases in which there is increased suspicion for cardiac involvement with COVID-19, initial testing should involve electrocardiography (ECG), measurement of cTn with a high-sensitivity assay, and echocardiography. Cardiology consultation is recommended for patients who have ECG or echocardiographic abnormalities that may be associated with myocarditis or an increasing cTn level.

CMR is recommended in patients who are hemodynamically stable with suspected myocarditis, and hospitalization is advised for those with definite myocarditis that is either mild or moderate in severity, preferably at an advanced heart failure center. Patients who have fulminant myocarditis should be managed at centers with expertise in advanced heart failure, mechanical circulatory support, and other advanced therapies.

Corticosteroids are recommended for patients with myocarditis and COVID-19 pneumonia with a continuing need for supplemental oxygen. Nonsteroidal anti-inflammatory drugs, colchicine, or prednisone may be used in patients with suspected pericardial involvement. Intravenous corticosteroids may be considered in patients who have suspected or confirmed COVID-19 myocarditis with hemodynamic compromise or multisystem inflammatory syndrome in adults, and empiric use of corticosteroids may be used for patients with biopsy evidence of severe myocardial infiltrates or fulminant myocarditis, while weighing the infection risk. Guideline-directed medical therapy for heart failure should be initiated and continued after discharge as appropriate.

According to the US Vaccine Adverse Event Reporting System, myocarditis after COVID-19 mRNA vaccination is rare, with the highest observed rates occurring in male individuals aged 12 to 17 years after the second vaccine dose.

“COVID-19 vaccination is associated with a very favorable benefit-to risk ratio for all age and sex groups evaluated thus far,” stated the committee. “In general, vaccine-associated myocarditis should be diagnosed, categorized, and treated in a manner analogous to myocarditis following SARS-CoV-2 infection.”

The committee noted that systematic, cross-sectional data are needed to understand the frequency, type, and severity of myocarditis and myocardial involvement. “Randomized trials are also needed to better understand the preferred means to test and treat patients with myocarditis related both to SARS-CoV-2 infection and mRNA vaccination,” they wrote.

Postacute Sequelae of SARS-CoV-2 Infection

The committee defined PASC as a constellation of new, returning, or persistent health problems in individuals 4 weeks or more post–SARS-CoV-2 infection. PASC–cardiovascular disease (CVD) encompasses a broad group of cardiovascular conditions that include myocarditis and other forms of myocardial involvement, pericarditis, new or worsening myocardial ischemia, microvascular dysfunction, nonischemic cardiomyopathy, thromboembolism, cardiovascular sequelae of pulmonary disease, arrhythmia, and other conditions.

PASC–cardiovascular syndrome (CVS) includes a variety of cardiovascular symptoms, without objective evidence of cardiovascular disease using standard diagnostic testing. Typical symptoms include tachycardia, exercise intolerance, postexertional malaise, palpitations, chest pain, and dyspnea.

Among patients with cardiovascular symptoms and suspected PASC, an initial testing approach may include the following: basic laboratory testing (including cTn), ECG, echocardiography, an ambulatory rhythm monitor, chest imaging (X-ray or computed tomography), and pulmonary function tests.

The committee recommends cardiology consultation for patients with PASC who have the following: abnormal cardiac test results, known cardiovascular disease with new or worsening symptoms or signs, documented cardiac complications during SARS-CoV-2 infection, or ongoing cardiopulmonary symptoms that are not otherwise explained.

Recumbent or semirecumbent exercise is advised initially for patients with PASC-CVS and tachycardia, exercise or orthostatic intolerance, or deconditioning. Transitioning to upright exercise can be done after orthostatic intolerance improves. Initial exercise duration should be limited to 5 to 10 minutes a day, with gradual increases as functional capacity improves, according to the committee.

Salt and fluid loading are nonpharmacologic treatments that may be beneficial for symptomatic relief for patients with tachycardia, palpitations, or orthostatic hypotension, along with beta blockers, nondihydropyridine calcium-channel blockers, ivabradine, fludrocortisone, and midodrine.

“Given that the total cost of PASC to patients and their families, the health care system, payers, and society at large is likely to be substantial, there is a critical need to identify ways to better meet the needs of those with this condition,” the committee stated.

Return to Play

The committee also provided updated guidance related to resumption of athletics and intense exercise training after SARS-CoV-2 infection.

The committee advises that athletes who are asymptomatic after recent SARS-CoV-2 infection may resume exercise training after 3 days of exercise abstinence in self-isolation. Athletes who have mild or moderate noncardiopulmonary symptoms after recent SARS-CoV-2 infection may resume exercise training after their symptoms have resolved, and those with remote infection of 3 months or more without ongoing cardiopulmonary symptoms can resume exercise training without additional testing.

Athletes who are recovering from COVID-19 with ongoing cardiopulmonary symptoms such as chest pain or tightness, palpitations, or syncope or who require hospitalization with increased suspicion for cardiac involvement should have triad testing (ECG, cTn, and echocardiography). Triad testing should also be conducted in athletes who develop new cardiopulmonary symptoms after resuming exercise training. The committee recommends CMR if triad testing is abnormal or cardiopulmonary symptoms persist and that athletes with myocarditis should abstain from exercise for 3 to 6 months.

Maximal-effort exercise testing or an ambulatory rhythm monitor may be beneficial for assessing athletes with persistent cardiopulmonary symptoms and either normal CMR or CMR that shows other forms of myocardial or pericardial involvement. The committee advises that maximal-effort exercise testing should only be performed after CMR has excluded myocarditis. CMR for screening athletes who are asymptomatic or who have noncardiopulmonary symptoms is not likely to be effective, and repeat cardiac testing is not needed in athletes with recurrent COVID-19 in the absence of cardiopulmonary symptoms.

“Widespread resumption of competitive sports will come with rare but devastating adverse events, including sudden cardiac death, that well predate COVID-19,” noted the committee. “Accordingly, it will be important to limit automatic attribution of such events to COVID-19 without further detailed evaluation.”

Clinical Implications

These guidelines are intended to help clinicians understand when testing may be warranted, as well as when it is not, and the recommendations may change over time as understanding of the issues increases.

For myocarditis and PASC, significant opportunities exist to better understand their epidemiology, underlying mechanisms, predisposing risk factors, and preferred approaches for evaluation and management. Regarding return to play, according to the committee there is a need to more rigorously define how long cardiovascular abnormalities persist and the relative benefits of exercise training in patients with PASC.

“Beyond the indirect effects and undesirable consequences that COVID-19 has had on care delivery, it also remains to be seen how new variants and vaccine breakthrough infection will affect cardiovascular health,” the committee concluded. “Improved understanding of the associated near- and long-term consequences will be key in helping to improve clinical outcomes.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Writing Committee; Gluckman TJ, Bhave NM, Allen LA, et al. 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Published online March 14, 2022. doi: 10.1016/j.jacc.2022.02.003