Management of Persistent Post-COVID-19 Symptoms

Initial Evaluation and Stratification

The American College of Cardiology recommends a multidisciplinary approach for patients with Post-Acute Sequelae of SARS-CoV-2 (PASC), coordinated by a primary care physician with specialists in pulmonology, cardiology, neurology, rheumatology, and infectious diseases 2
Initial laboratory tests should include complete blood count, basic metabolic panel, cardiac troponin, and C-reactive protein 2
Functional respiratory tests are recommended to exclude compromise of carbon monoxide diffusion capacity, pulmonary fibrosis, or bronchial hyperreactivity 2
The American College of Cardiology suggests considering a more in-depth evaluation for PASC with cardiovascular involvement (PASC-CVD) given the clinical presentation and elevated IgG SARS-CoV-2 levels 1, 2

Cardiac magnetic resonance (CMR) is recommended to exclude subclinical myocarditis or myocardial fibrosis, particularly important in the post-COVID context with persistently elevated IgG SARS-CoV-2 levels 1, 3
Ambulatory cardiac rhythm monitoring (Holter 24-48 hours) is indicated to exclude intermittent arrhythmias not documented on standard ECG 2
A 10-minute active stress test in an upright position is recommended to evaluate dynamic changes in blood pressure and heart rate, excluding orthostatic hypotension and postural orthostatic tachycardia syndrome (POTS) 2

Colchicine at low doses may be considered for persistent chest pain with an inflammatory component, with a gradual reduction plan based on symptoms 1, 3
The American College of Cardiology does not recommend routine use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the absence of documented pericardial involvement, given the risk of increased inflammation and mortality in isolated myocarditis 3, 4

Follow-up surveillance is essential and should include ECG, echocardiogram, ambulatory rhythm monitoring, and CMR at 3-6 months from initial presentation 1, 3, 4
Monitoring of inflammatory markers (ferritin, CRP, D-dimer, IL-6) every 3 months until normalization is recommended 1
Consultation with a cardiologist is recommended for persistent cardiorespiratory symptoms not otherwise explained, documented cardiac complications during SARS-CoV-2 infection, or abnormal cardiac test results 2
Consultation with an allergist/immunologist for elevated IgE and possible histamine intolerance is suggested 5
Consultation with a rheumatologist if signs of systemic autoimmune disease emerge, given the context of persistent inflammation 1