*Post Covid -Heart**

It is 2 -3 months since Second wave -But patients keep flocking the OPD with Complaints of Paplitations tachycardia exhaustion fatigue. Many of them being even unaware of past Covid infection. It is important for every doctor to recognise post covid cardiac issues .

*Clinical manifestations*

1. *Chest pain in up to ~20%* of COVID-19 survivors at *60 days follow-up*

2. *Palpitations in 9% and chest pain in 5%* even at 6months follow-up

3.An *increased incidence (~8%) of stress cardiomyopathy* during the COVID-19 pandemic compared with pre-pandemic (~1.5%) .

However mortality and re-hospitalization rates in these patients are not higher

4. *Cardiac MRI suggest that ongoing myocardial inflammation may be present* in as high as *60% more than 2months after a diagnosis* of COVID-19

5. *Myocarditis in 15% of young athletes* (Diagnosed by Cardiac MRI) even after mild or even asymptomatic Covid

*Pathophysiology*

Mechanisms of cardiovascular sequelae in post COVID stage

◆ direct viral invasion,

◆ downregulation of ACE2,

◆ exaggerated inflammation in COVID-19 perpetuates arrhythmias including tachycardia due to a heightened catecholaminergic state by cytokines such as IL-6, IL-1 etc.

◆ the immunologic response

affecting the myocardium, pericardium and even conduction system.

*Effects*

◆Recovered patients may have persistently increased cardiometabolic demand Leading to reduced cardiac reserve.

◆Myocardial fibrosis or scarring, resulting cardiomyopathy from viral infection, Can lead to

◆ *re-entrant arrhythmias* .

◆ *Autonomic dysfunction after viral illness*

◆ *postural orthostatic hypotension*.

🔰 *_Management_*.🔰

1. Serial clinical and imaging evaluation with *ECG and ECHO at 4–12weeks* in patients with persistent cardiac symptoms.

2. *Abstinence from competitive sports or aerobic activity for 3–6months until resolution of myocardial inflammation by cardiac MRI or troponin normalization*

🔰3. *RAAS inhibitors (Ramipril Telmisertan etc) are safe and should be continued in stable cardiovascular disease*.

🔰4. Instead, abrupt cessation of RAAS inhibitors may be potentially harmful.

🔰5. In patients with LV dysfunction, usual medical therapy should be optimized as tolerated.

🔰4. Postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia (Palpitations) may benefit from a *low-dose beta blocker*.

🔰5. Careful Attention is warranted in use of anti-arrhythmic agents (eg, amiodarone) in patients with pulmonary Fibrosis.

6. *🔰*Bradycardia in Covid*

*Transient sinus bradycardia is a possible manifestation*

*Etiology*

*◆severe hypoxia,

*◆inflammatory damage of cardiac pacemaker cells, and

*◆exaggerated response to medications are possible triggers.

*◆High levels of pro-inflammatory cytokines may act directly on the sinoatrial (SA) node contributing to the development of bradycardia.

🔰 *Bradycardia may be a warning sign of the onset of a serious cytokine storm in Sick Patients*.

🔰 *Some patients may develop bradycardia with the use of Favipiravir and Remdesivir.*

– Usually settes in 2 weeks time with recovery.