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Before Jennifer Fagan got Covid-19 in March 2020, she considered herself somewhat of a fitness enthusiast. She used to go running two or three times a week and took a hot yoga class almost every other day. But several weeks after she recovered from the initial stages of the illness, she still felt excruciating pain in her chest and got winded all the time. By June, she started having heart palpitations. “I told my doctor that I felt like I was in the body of a 70 or 80 year old,” Ms. Fagan recalled.
She saw a cardiologist and a pulmonologist, but the specialists could not find any health problems in initial tests on the 48-year-old. So Ms. Fagan eventually worked up to a running routine again. Then, in December 2020, she went into cardiac arrest after returning from a slow, two-mile walk.
At first, neither her husband nor the emergency medical workers could figure out what went wrong. They took her to the hospital, where doctors diagnosed a rare inflammation of the heart muscle known as myocarditis and implanted a defibrillator to stabilize her heart. But that was not the end of her heart issues. While she was still in the hospital, Ms. Fagan started having bouts of extreme dizziness. And she’s experienced a range of long Covid symptoms ever since, from fatigue to shortness of breath, as well as rapid or irregular heart rhythms.
Studies estimate that some 10 to 30 percent of people who have been infected with the coronavirus may develop long-term symptoms. And in a recent analysis of Department of Veterans Affairs health records from more than 150,000 people who contracted Covid-19, researchers found that Covid survivors had a “substantial” risk of developing cardiovascular disease up to a year after their initial illness, even if their infections never landed them in the hospital. When compared with millions of other patients who were never infected, Covid survivors were 63 percent more likely to have a heart attack and 52 percent more likely to have a stroke. They also had higher risks of heart failure, irregular heart rhythms, blood clots and inflammatory disorders such as pericarditis and myocarditis.
The problem is that traditional medical exams for diagnosing heart conditions — like electrocardiograms (EKGs), ultrasounds and other functional tests of the heart — often show that people who’ve had Covid-19 have no obvious heart damage. “When we do all those tests, they’ll actually look pretty good,” said Dr. Ruwanthi Titano, a cardiologist at Mount Sinai’s Center for Post-COVID Care in New York City. So doctors have had to reimagine how they diagnose and treat people with heart issues that linger long after a coronavirus infection.
If you have heart-related symptoms, whether it is chest tightness or pain, shortness of breath, a racing or skipping heart beat, dizziness or extreme fatigue, your health care provider may still want to perform these basic tests to rule out any abnormalities or impairments in the cardiovascular system, Dr. Titano said. But new studies suggest that damage to the nerve fibers that help control circulation may actually be to blame. And this damage has a name: small fiber neuropathy.
Luckily, the tools to treat many types of post-Covid neuropathy already exist. “People are not going to have to live with this for the rest of their lives,” said Dr. Salim Hayek, a cardiologist and co-director of Michigan Medicine’s Covid-19 Long Haul Clinic in Ann Arbor. “The vast majority of the time, these symptoms ranging from palpitations to lightheadedness resolve within six months of treatment.”
According to data collected by the Centers for Disease Control and Prevention, most people recovering from Covid-19 benefit from tailored physical and mental health rehabilitation services.
Amy Ridgway, a physical therapist and manager at Emory Outpatient Rehabilitation in Partnership with Select Physical Therapy, said that many long Covid patients can start seeing immediate improvement with a few simple breathing exercises. “One of the first things that we teach is diaphragmatic breathing,” she said. Practicing deep belly breathing every day allows the lungs to soak up much needed oxygen and is known to help reduce pain and anxiety. “It’s a great technique for anyone,” Ms. Ridgway said.
If you experience symptom flares after any kind of exertion, a therapist may recommend that you manage your daily activity levels or keep a diary to help anticipate which activities may be too mentally or physically draining. This self-pacing technique, often used by those with chronic fatigue syndrome (also known as myalgic encephalomyelitis, or ME/CFS), assumes that people have a set quota of energy they can spend each day. So small tasks, like showering or getting dressed, may use up less of their energy, whereas vacuuming or walking to the end of the driveway may drain their energy much faster, leading to something called post-exertional malaise.
Conserving energy throughout the day can help reduce post-Covid fatigue while patients recover, Ms. Ridgway said. “It’s a little bit of a different treatment approach than a lot of other physical therapies, but we really want to make sure we’re doing everything that we can to empower these patients.”
Doctors and therapists agree that people with long Covid need to return to exercising at a very slow pace, often by starting with relearning basic aerobic conditioning and doing recumbent strength training before advancing to more intense, upright movement. This may involve trying to activate your core while in a supine or sideways position, performing balance exercises or doing seated cardio on a recumbent bike or rowing machine. A health care provider will likely monitor your heart rate, blood pressure and oxygen levels while you perform these exercises and ensure that you don’t experience a skipping heart beat or any other cardiovascular symptoms, Dr. Titano said.
Eventually, you may feel comfortable trying an elliptical or walking on a treadmill. Your doctor or physical therapist may also ask you to count your steps or attempt to climb the stairs in your home a certain number of times every day. One of the goals that Ms. Fagan’s cardiologist set was to walk 5,000 steps a day — a target the specialist suggested in October 2021. “It’s March now and I just reached it,” she said.
Progress in managing long Covid symptoms can be excruciatingly slow, so it is often encouraging to be able to see your improvements over time. People may track their data using a heart rate monitor in a smartwatch, a blood pressure cuff or pulse oximeter if they have one at home. Health care providers may advise that you enlist a family member or friend to help you use some of these devices, and to ensure that you remain safe while performing any exercises. “It’s nice to be able to track progress,” Ms. Fagan said. “It personally helps me because the progress is so incredibly slow. You just don’t see it day to day. You do not even see it month to month. It’s more yearlong progress.”
If you experience really debilitating symptoms that prevent you from doing everyday tasks — like the laundry, going to work or taking care of your kids, for example — you may need additional help from prescription medication and closer monitoring by a health care professional, Dr. Hayek said. Depending on your individual heart disease risk and current symptoms, certain blood pressure medications like beta blockers or calcium channel blockers can help alleviate extreme dizziness and treat chest pain and abnormal heart rhythms, he said. And these drugs can be tapered off once your cardiovascular symptoms abate.
Adolescents and young children with long Covid, however, are not eligible for many heart drugs. When seeing young patients, Dr. Sindhu Mohandas, an infectious disease expert at Children’s Hospital Los Angeles, said she tends to recommend more lifestyle changes that, in addition to physical therapy, may help patients focus in school and rebuild their endurance for sports.
Lifestyle changes, like managing daily energy reserves or slowly building up your capacity for exercise, may seem trivial, but they can have a large effect on reducing your long-term risk of heart attack or stroke, said Dr. Salim Virani, a cardiologist at Baylor College of Medicine in Houston. And health care providers are constantly learning of more ways to help long-Covid patients improve their health, he said.
As for Ms. Fagan, she is hopeful that working with her physical therapists and doctors will help her continue to rebuild her fitness levels and eventually return to normal life. Just last month, she was able to go to a restaurant with friends and then walk to a play at her daughter’s high school, which “was a big deal.”
“Sometimes there’s nothing to do but to slow down,” she said. “And that’s an OK thing.”
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