Respiratory, Cardiac, and Neurological Red Flags for Long COVID

Becky McCall

October 18, 2021

Editor's note, 18 October 2021: This article was updated to correct the title 'occupational therapists'.

Watch for the big three red flags – cardiac (ischaemia, tachyarrhythmia, myocarditis and pericarditis), neurological (TIA and stroke) and respiratory (pulmonary embolism) in patients with long COVID, says the GP lead of one of the country's first long COVID clinics.

Dr Harsha Master, lead in COVID assessment and rehabilitation, Hertfordshire Community NHS Trust, spoke to GPs gathered at the Royal College of General Practitioners (RCGP) annual conference 2021.

"Don't just go on observations and parameters, if the patient isn't improving then send them in along the usual pathways such as hospital admission or referral to a rapid-access chest pain clinic," said Dr Master, sharing her clinic's experience of more than 800 long COVID cases. "We don't always know what is going on, and acute pathology must be ruled out first."

She related the story of one patient, a woman of 50, who was previously fit and well, with ongoing COVID symptoms, who went to A&E three times. "Her resting oxygen saturations were normal, her pulse was normal, her ECG was normal, her D-Dimer was normal. On her third presentation [at A&E] she was found to have a pulmonary embolism, 3 months down the line."

Multidisciplinary Team to Treat a Multisystem Disorder

The East and North Hertfordshire clinic was one of the first to see ex-hospital as well as non-hospitalised COVID patients. The service went live in August 2020.

Dr Master described her approach to treating patients upon presentation at the clinic. "Patients must have been seen by their own GP first. Long COVID is a diagnosis of exclusion, and you have to work the patients up in the same way that you usually would."

With breathlessness, she advised considering respiratory and cardiovascular causes. "Do the BNP [B-type natriuretic peptide]. Rule out acute pathology, because malignancy can present very similar to COVID symptoms. Think laterally. Resting oxygen saturations and the D-dimer have not always been found to be reliable post COVID."

Rehab and Medical Investigation Combined Most Useful

The long COVID clinic has physiotherapists, speech and language therapists, occupational therapists, pulmonary rehabilitation, chronic fatigue specialists, a rehab coordinator who coordinates care of patients across the pathway, and Dr Master herself as the COVID rehab GP.

"It seems a combination of medical investigations and rehabilitation works the best," she said. "If you do the rehab without the medication, or vice versa, it does not work well."

Most referrals are from GPs and not many from hospital. "We find 85% are White British, and 15% other Ethnic Minorities. This is seen nationally too. There are more women [66%] than men [34%]," she said, reporting her clinic's data.  

As for unusual features, Dr Master has seen patients who were previously fit and well. They usually had a long initial illness of over one week. They had multiple (eight to nine) symptoms presented together, for example, brain fog, chest pain, palpitations, ENT (ear, nose and throat) symptoms, and anxiety among others. These are clinic observations not data from a trial, she stressed.

"Long-term symptoms seem to echo the initial illness. Fatigue is not just fatigue, it's a post-exertional malaise - a 'boom and bust' phenomenon. These were fit people who can't now walk up the stairs," she explained. "Patients typically have good days and bad days and on the bad they exert and then crash."

Other typical symptoms include autonomic dysfunction (postural tachycardia syndrome, POTS), and features of MAST Cell Activation Syndrome (MCAS), new-onset food intolerance, diarrhoea. "ENT symptoms, for example mild sinusitis is often remarkably worse since COVID in these patients," Dr Master pointed out.

Majority Are White British Women

Among long COVID patients who were hospitalised for COVID, most were over 50, male, more were African, Caribbean, and Asian, and they already had a propensity towards having cardiovascular disease, diabetes, and hypertension. They were also more likely to have had adverse sequelae of the acute illness, said Dr Master. In contrast, those not hospitalised for COVID were more often between 20-60 years, female, White, previously fit and well and had multiple organ syndromes.

She outlined some theories behind long COVID, although she admitted it was observational and from her clinic only. "It's multi-system – heart, brain, lungs, liver. It's thought to be an exaggerated immune response causing inflammation and autonomic dysregulation. There's also a possible mechanism of endotheliopathy and immunothrombosis, and a possible MCAS leading to hyper inflammatory response."

In terms of barriers to recovery, Dr Master said there was often a lapsing-remitting pattern, with stress, anxiety, sleep disruption, overwork, over exertion, and poor gut health at play.

Scottish GP With Long COVID

Also addressing the conference and sharing her story was Dr Amy Small, locum GP in Lothian, Scotland, and clinical advisor to Chest, Heart and Stroke, Scotland.  She has long COVID, as does her husband. She sat on a Scottish Government group looking at support for patients with long COVID in Scotland.

Explaining her acute symptoms, she recalled, "I had a breathlessness that wouldn't go away. I still had fever a month in… my speech was slow, I had brain fog, and couldn't climb the stairs without stopping." After lots of tests to rule out other causes, she was sent home.

"We took it in turns to put the TV on for our kids because my husband was struggling too. After trying to go back to work in June, it triggered a relapse, where I went home and stayed in bed for 10 days. I could hardly speak because my face muscles hurt so much."

In September, Dr Small lost her job. "We need to remember the impact of long COVID on patients' lives.

"I had some propranolol left.. and took it thinking it might help. Interestingly, it did. I was less breathless, though I wondered if I had POTS." Her GP gave her bisoprolol and two weeks later she was keeping up with her 4-year old again, she said.

She improved such that by January she returned to work as a locum; by Easter she could walk 15,000 steps, and by the summer she was doing a couch-to-5K run. At summer's end, she was off her medications and exercising five times a week.

In terms of symptoms, Dr Small said she experienced headaches, breathlessness, tinnitus, palpitations, fatigue and myalgia. Headaches are common among long COVID patients, she said, and they may also have anxiety, food intolerances, hoarse voice and other ENT symptoms. She highlighted that breathlessness is not always respiratory but sometimes cardiovascular. "Mine wasn't just respiratory in cause, but it was driven by my POTS. We need to remember when seeing long COVID not to just do a chest X-ray and say you're okay because your lungs are fine. There might be other causes."

Presented on Friday 15 October, 2021 at the Royal College of General Practitioners (RCGP) annual conference 2021.

Drs Master and Small have declared no conflicts of interest.

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