ECG should be included in COVID-19 follow-up care, but it is unclear how often this test should be performed.


COVID-19 and Cardiac Inflammation: What Do We Know Now?

By Sarah Handzel, BSN, RN

New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.

The long-term cardiac effects of the novel COVID-19 virus remain uncertain. Many studies suggest that serious complications may result from COVID-19 infection, especially among people with certain preexisting conditions like underlying cardiovascular disease, but researchers do not fully understand which factors may increase the likelihood of future issues for some individuals.

An article published in Life Sciences in late 2020 suggests that COVID-19 may cause or exacerbate cardiac injury related to cardiac inflammation. Early autopsies of people who have succumbed to the disease noted infiltration of inflammatory mononuclear cells in the myocardium, which may hint at the underlying molecular mechanisms driving cardiac damage.

As more patients survive COVID-19, it is unclear how great a role cardiac imaging and monitoring tests will play in continued follow-up care. ECG screenings to detect further cardiovascular damage should almost certainly factor into continued treatment plans, but how often these tests should be performed remains controversial.

Cardiac Inflammation Mechanisms Resulting in Injury

The same paper in Life Sciences describes the ACE2 receptor as the main anchor point for the SARS-CoV-2 virus. Initial inflammatory processes are triggered in the lungs, which eventually lead to systemic hyper-inflammation as pro-inflammatory cytokines are released into the body.

This so-called "cytokine storm" results in the inflammation of multiple organs across various organ systems, leading to eventual tissue damage and, for some, death. For patients with preexisting CVD, elevated levels of cardiac injury biomarkers, such as C-reactive protein and high-sensitivity cardiac troponin I, may be the first signs of complications, including severe right ventricular dilation, cardiac necrosis, or infiltration of immune cells into the myocardium.

The exact relationship between COVID-19 and cardiac inflammation is still unclear, but increasing evidence points to the inflammatory response as a main factor in COVID-19-related cardiac injury.

The "Big Ten" Myocarditis Controversy

In the fall of 2020, initial data suggested that approximately 30 to 35% of American student athletes who became infected with COVID-19 also developed myocarditis regardless of the severity of infection, as reported by CNN. In response to this information, college sports teams in the "Big Ten" put a hold on fall athletic seasons.

However, the statistic was quickly refuted. Some suggested the recommendation to halt all athletic events was based on outdated information, but doctors still noted that both symptomatic and asymptomatic individuals infected with COVID-19 showed significant inflammation of the cardiac muscle in cardiac MRI scans.

At this point, it is unknown whether COVID-19 will decrease athletic performance over time and result in the loss of elite student athletes from team rosters. Researchers at Johns Hopkins Medicine and Louisiana State University assert that myocarditis is actually a rare complication following COVID-19 infection, affecting only 1.4 to 7.2% of sick individuals.

It is also unclear what role vigorous exercise has in exacerbating COVID-19 complications. A study published in HSS Journal suggests that all patients, including athletes, should follow the 50/30/10 rule, where conditioning volume for the first week after COVID-19 symptoms resolve is reduced by at least 50% of the normal exercise load, followed by 30%, 20%, and finally 10% during the following three weeks.


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ECG and Post-COVID-19 Syndrome

According to Mayo Clinic, many patients experience symptoms after their initial recovery from COVID-19 as part of a condition termed post-COVID-19 syndrome. Common symptoms shown to continue over time include fatigue, shortness of breath, and chest pain. Additionally, cardiac rhythm disorders, such as sinus tachycardia, ventricular fibrillation, Afib, and conduction defects related to intracellular calcium and potassium regulation, may warrant increased surveillance well into the future.

Several studies suggest increased incidences of cardiac arrhythmias related to myocardial injury following COVID-19 infection, including articles in Heart Rhythm, Trends in Cardiovascular Medicine, and Circulation: Arrhythmia and Electrophysiology. Patients with acute cardiac injury related to arrhythmia were shown to have higher mortality rates compared to those without cardiac injury.

Many physicians adhere to guidance recommending frequent ECG monitoring as part of follow-up care for those diagnosed with COVID-19. Symptoms suggesting possible arrhythmia, such as heart palpitations or irregular heartbeats, should be investigated with at least an initial ECG before turning to other screening tests like cardiac MRI.

However, according to the American Heart Association, some researchers believe that cardiovascular damage related to cardiac inflammation may eventually heal itself. Until the exact relationship between cardiac muscle inflammation and COVID-19 is understood, physicians should continue to use best practices based on the latest guidelines from official sources.


Sarah Handzel, BSN, RN has been writing professionally since 2016 after spending over nine years in clinical practice in various specialties.

The opinions, beliefs, and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.