Is chest pain after COVID-19 serious? How long should you expect symptoms to linger? When should you start worrying? A cardiologist explains

On the road to full recovery after COVID-19, many survivors have been complaining of long-term symptoms and health complications that go well beyond the lungs. Although respiratory symptoms such as coughing and feeling breathless had been observed among the lingering symptoms in severe cases of COVID-19, physicians are now increasingly reporting wider issues in the body, including in the brain, gut and heart.

From fatigue, mental fog and insomnia to heart palpitations, chest pain and muscle ache, these flurry of symptoms that continue weeks or months after the initial infection have been named "Long Covid" by the scientific community. Different countries have different time thresholds for these symptoms to be classified as such, with this figure ranging anywhere from four to 12 weeks.

These are thought to be linked to the coronavirus damaging endothelial cells that line all the blood vessels in our body during its fight against our immune system. This damage can disrupt our body's supply of blood, leading to blood clots that can trigger heart attacks and reduce blood and oxygen flow to tissues. COVID-19 can cause a host of heart-related problems, including rhythm disturbances in the form of fast or irregular beating, heart palpitations and inflammation of the muscle and its surrounding lining. A review in the Journal of the American College of Cardiology found that at least 25% of hospitalized coronavirus patients experienced heart complications.

Although people with pre-existing heart and circulatory diseases are known to have a higher risk of developing complications due to COVID-19, otherwise healthy people can also suffer from such long-term effects. For that, Istanbul-based associate professor and board-certified cardiologist Muhammed Keskin says check-ups after overcoming the disease should not be skipped.

However, with the number of cases still not below the desired levels and the mass vaccination campaign faltering over the total lockdown in Turkey, Keskin says specialist surgeries and policlinics will continue to have very limited operating capacity. The situation is no different in the U.K. either, with the National Health Service (NHS) reporting a backlog of 4.7 million people for non-COVID-19 care.

"Right now, most doctors are working in COVID-19 wards and designated COVID-19 emergency hospitals. A lot of my patients (who have survived COVID-19) cannot find appointments in branches such as cardiology or pulmonary medicine, which are the ones most needed post disease."

Heart attacks and hypertension can often go unnoticed, leading to fatalities where early intervention or timely monitoring could have saved lives. But the latest measures have partly been promising.

"The number of cases has drastically dropped over the last 3 weeks due to the lockdown. It's now down to a third of what it was. There has been great relief in ICUs, there are more beds for patients. But this is not the time to be complacent."

Keskin stresses that vaccinating at least 50% of the population is crucial to prevent more people from experiencing complications and inundating hospitals with news waves of patients.

"If we want a semblance of normalcy restored, we need to reach (a vaccination rate of) 70% or above," he adds.

Until then, health care personnel and patients will have to deal with the damage left behind by COVID-19.

"(COVID-19) can cause widespread damage to the body. It also takes time for the inflammation in the lungs and other parts of the body to wane, and disappear. You may be free of the disease but the aftermath is hard on the body. The damage continues even when the virus has left."

"We continue to see these effects for as long as three months but we see them more often in people with chronic disease such as hypertension, obesity, sleeping and psychological disorders," says Keskin.

On that note, here are the seven potential long-term side effects to the heart post-COVID-19.

1. Myalgia
Or in other words muscle pain, this is one of the most common side effects of virus-borne diseases. Such aches happen because lactate accumulates in muscle tissue while the body fights off the virus, directly causing inflammation of the muscle tissue. Although it may make the patient think there is something wrong with the heart, for the majority of cases it is purely muscle ache.

But this is not specific to COVID-19. If you have ever had the flu (influenza), you will likely have experienced muscle and joint pain. In COVID-19, since spasms and inflammatory reactions are more common in chest muscles, chest pain is felt more often by patients.

Keskin says such muscle problems usually resolve spontaneously and the chest pain should disappear in two to three weeks. Applying heat, taking painkillers or muscle relaxants usually resolve the problem. It is not a life-threatening situation.

2. Tietze Syndrome
Another cause of chest pain after COVID-19 is Tietze Syndrome, also known as costochondritis. This happens as a result of an inflammatory reaction where the ribs join the breastbone and often develops after viral diseases.

According to Keskin's observation in COVID-19 wards in Turkey, for 46% of the patients who apply to the emergency room (ER) with chest pain, the cause of pain is musculoskeletal diseases and one of the most common causes is Tietze syndrome. The chest pain associated with this is generally unaffected by effort and changes with position. The pain is a stabbing sensation. You may also feel an increase in pain when breathing deeply. But this kind of pain responds well to painkillers.

This syndrome is usually short-lived and resolves on its own. In some cases, it may take a few months.

3. Myocarditis
This is the inflammation of the heart muscle and it occurs when the immune system gets out of control and damages the muscle while trying to destroy the virus.

There are three possibilities for a COVID-19 patient with myocarditis:

The heart heals completely
Heart failure becomes chronic
The patient develops sudden heart failure which leads to death
With this disease, unfortunately, the chest pain does not fall into a particular category. It can be stinging, stabbing, or in the form of pressure and burning similar to a typical heart attack.

This disease is of vital importance and an electrocardiogram (ECG), echocardiogram or cardiac MRI may be required for diagnosis.

4. Pericarditis
This is the inflammation of the pericardium or the cardiac membrane. This disease also emerges as a side effect of the war against the virus. Sometimes the virus can directly target the pericardium.

The most common symptom of pericarditis is usually severe chest pain, described as sharp and stabbing. The pain is felt more when coughing, swallowing, breathing deeply or lying down. The pain may decrease slightly when sitting or leaning forward. Anti-inflammatories and pain medication may be required in the treatment of sudden (acute) pericarditis.

"What scares us in COVID-19-related pericarditis is the sudden increase in pericardial fluid that puts pressure on the heart and impairs heart function. We call this situation pericardial tamponade," says Keskin. This situation calls for urgent intervention. A catheter is pushed through the chest wall into the tissue around the heart to drain excess fluid. Early treatment has a good response and positive clinical outcomes.

5. Coronary artery thrombosis
Clots can also form in the heart vessels after severe cases of COVID-19. Although asymptomatic until there is a significant construction, patients often report crushing chest pain, a heavy-feeling heart, light-headedness and shortness of breath.

One of the side effects of the coronavirus is its tendency to cause clots in all body vessels. If this coagulation occurs in the heart vessels and restricts blood flow within the heart, it can damage heart tissue or cause a sudden heart attack.

6. Heart attack
Heart attacks after COVID-19 can also happen due to the rupture of the plaques in the heart vessels, which subsequently leads to the occlusion of the arteries. But this is generally seen in individuals with underlying cardiovascular disease, with smoking, diabetes, high blood pressure and obesity being the main risk factors.

Unlike clot-caused heart attacks, plaques or fatty deposits that have formed over the years in the veins and have already partially narrowed the vessel, rupture and completely block the vessel due to the infection. This narrowing or blockage causes pain that is termed angina pectoris.

Chest pain caused by a heart attack is often a sensation of pressure, burning, and squeezing in the middle of your chest and can spread to the chin, left arm and back. As soon as you experience such pain you should call 112 and go to hospital. Time is of the essence here.

Keskin says in case of a heart attack, the first two hours are of vital importance, and if the occluded blood vessel cannot be opened within this timeframe, the damage is usually permanent and the risk of death increases.

7.Pleural effusion/pleuritis
In patients who develop pneumonia due to COVID-19, there may be pain in the chest and more often in the sides of the abdominals due to damage to the lung tissue or fluid accumulation in the pleura, the tissue that protects and cushions the lungs.

The cause of this type of pain is usually the damage caused by the coronavirus to the lung. It is characterized by flank pain (or side abdominal pain) and a stinging/poking/stabbing sensation while breathing and tightness or shortness of breath. As the disease starts to improve, this pain will gradually subside. Usually, no special treatment is required.

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