Management of patients with post-acute sequelae of SARS-CoV-2 (PASC)

Oct. 11, 2022

Between 10% and 30% of patients who recover from acute COVID-19 experience post-acute sequelae of SARS-CoV-2 (PASC), also known as long COVID-19. The definition of PASC is evolving and includes a wide range of symptoms that vary in intensity and duration. Experts currently suggest that PASC should encompass symptoms that persist beyond three or four weeks after the onset of infection with the virus. Patients with PASC have an elevated risk of cardiovascular complications, including pulmonary embolism, arterial and venous thromboses, myocardial infarction, and stroke.

In June 2022, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) issued guidance on caring for patients with cardiovascular complications associated with PASC. The statement was drafted by a multidisciplinary team of physicians, clinicians and patient advocates, including physiatrist Carmen M. Terzic, M.D., Ph.D., director of cardiac rehabilitation at Mayo Clinic in Rochester, Minnesota.

The AAPM&R statement notes that the cardiovascular complications associated with PASC can negatively impact the life expectancy and economic productivity of patients, and that health care providers, health care systems and governments worldwide should prepare for these impacts. In this article, we highlight a few takeaways from the AAPM&R statement that are relevant for physical medicine and rehabilitation practitioners.

Understanding cardiovascular complications and symptoms in patients with PASC

The AAPM&R statement outlines several important points about PASC symptoms and their impact on cardiovascular health, including the following:

  • The severity of cardiac involvement in a patient with PASC often corresponds with the severity of the acute COVID-19 infection and whether the patient needed hospitalization, intensive care (ICU), and supportive respiratory and cardiac interventions.
  • PASC may involve the heart (myocardium, coronary vessels, conduction system) and affect the peripheral vasculature (venous thrombosis), the central vasculature (stroke and pulmonary embolism) and the body's autonomic control of the cardiovascular system.
  • Additional PASC-related cardiovascular symptoms include shortness of breath, fatigue, chest pain, palpitations, dizziness, abdominal bloating, leg swelling and impaired activity tolerance.

Cardiac rehabilitation approach to patients with PASC

According to Dr. Terzic and co-authors, patients with PASC and cardiovascular disease symptoms can qualify for and benefit from a cardiac rehabilitation program. The AAPM&R statement notes that cardiac rehabilitation programs should be considered for these patient groups:

  • Individuals with evidence of an acute coronary event during COVID-19
  • Individuals with evidence of new myocardial dysfunction and ejection fraction of ≤35%
  • Individuals with new heart valve disease requiring intervention and those who undergo heart or heart-lung transplant after COVID-19 myocarditis

Patients with mild to significant limitations related to PASC symptoms can be considered for a cardiac rehabilitation program after an evaluation by a cardiac rehabilitation physician and appropriate testing to guide the cardiac rehabilitation prescription. In general, cardiac rehabilitation for patients with PASC should include a medical evaluation, prescriptive exercise, cardiac risk factor modification, education and behavior modification. Cardiac rehabilitation programs can include monitored, symptom-guided, progressive activity as well as occupational and physical therapy, all of which should be tailored to the patient's individual needs and health risks.

"There are no evidence-based guidelines for exercise prescriptions after COVID-19 infection," explains Dr. Terzic. "Overall, our statement emphasizes the need to individualize rehabilitation programs for patients with PASC. We also urge health care providers to be cautious when making activity and exercise recommendations for these patients, as many of their symptoms are exacerbated by exertion. Exercise training after COVID-19 infection, especially for patients with post-COVID-19 syndrome, should usually begin conservatively and progress slowly to allow time for adaptation and prevention of a 'crash' or post-exertional malaise."

Contraindications to participating in cardiac rehabilitations for patients with PASC are similar to those outlined for the general population. Dr. Terzic suggests consulting the full AAPM&R statement for more information about management of patients with PASC, including contraindications, return-to-play guidelines for athletes with PASC and other details.

For more information

Whiteson JH, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of cardiovascular complications in patients with post-acute sequelae of SARS-CoV-2 infection (PASC). PM & R. 2022;14:855.

Refer a patient to Mayo Clinic.