‘Long Covid’ is a term used to describe ongoing symptoms four or more weeks following acute Covid -19 infection.1 It presents differently in every patient and can affect multiple organ systems, even after mild or even asymptomatic acute Covid -19.2 What is most commonly meant by long Covid is post-Covid-19 – defined by NICE as symptoms more than 12 weeks after acute Covid. Symptoms for post-Covid include fatigue, shortness of breath, mental problems, chest pain and dysfunction of smell and/or taste.2
Chest pain has been found to affect up to 22% of patients 2 months following acute Covid -19.2 In a large study presented by Huang et al, chest pain affected 5% of patients six months following discharge from hospital with Covid -19.3 In a cohort study of 100 patients, in whom 17% had atypical chest pain and 20% had palpitations two to three months following acute Covid-19, imaging revealed ongoing cardiac involvement in 78% of patients and signs of myocardial (or heart muscle) inflammation in 60%.4 Only one-third of patients had been hospitalised.
Does my patient have post-Covid-19 syndrome?
Whilst chest pain can be a symptom of post-Covid-19 syndrome, it is important to exclude alternative causes, particularly when this is the sole symptom of presentation. Clinical assessment of these patients should be the same as any patient complaining of chest pain: a detailed history of the nature and timing of pain, associated symptoms, past medical history and risk factors, followed by an examination and investigations or urgent referral as indicated.5 In order to ascertain whether the chest pain is related to Covid-19 or not, it is also essential to explore the course of their acute Covid -19 infection, including type and duration of symptoms and any hospital admissions or complications.
Patients should be referred urgently to the relevant acute services if they have acute cardiac chest pain or signs of severe lung disease, particularly if this symptom is in isolation to other symptoms.1 New or deteriorating symptoms must be investigated as they could be indicative of delayed effects of Covid-19.2 Specific, treatable causes of chest pain related to post-Covid -19 syndrome include respiratory complications such as pneumonia, pneumothorax (collapsed lung) or pulmonary embolism (blood clot in the lungs) and cardiovascular complications such as post-viral myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart).
In low risk patients, and depending on the clinical presentation, initial investigations that can be performed in primary care include:
- Full blood count
- C-reactive protein
- Creatine kinase
- Brain natriuretic peptide
- 12 lead ECG
- Chest x-ray
If there are clinical signs of pericarditis or myocarditis, patients should be urgently referred to the acute medical team for further investigation. Patients will need urgent ECGs, troponins and echocardiograms prior to treatment.
As per normal practice, patients who have suspected pulmonary embolism should be referred to ambulatory care or the acute medical team as appropriate, since treatment is the same as for non-Covid-19-associated pulmonary embolism.
Musculoskeletal chest pain can be managed in primary care with analgesia. Chest pain as a sole complaint is more likely secondary to a specific cardiac complication, as discussed previously, so referral directly to cardiology may be more appropriate.
If the chest pain is affecting your patient’s quality of life despite adequate analgesia, or they have multiple ongoing symptoms, patients can be referred a Long Covid clinic for a holistic, multidisciplinary team assessment. Here, they will usually undertake a medical assessment by a physician (often respiratory/general medic), a physiotherapist, occupational therapist and clinical psychologist. Depending on their symptoms, they may be referred for further imaging, including CT scans and echocardiograms, or referred to cardiology for more detailed investigations.
Further role of the nurse
Patients may bring up their chest pain in consultation for various reasons. As with any chest pain, if you have any concerns, check with the patient’s normal medical practitioner. If the chest pain is ongoing and has been diagnosed as part of post-Covid-19 syndrome, there are various resources you can highlight to the patient:
- National Institute of Clinical Excellence, “COVID -19 rapid guideline: managing the long term effects of COVID -19,” 18 December 2020. [Online]. Available: https://www.nice.org.uk/guidance/ng188. [Accessed 17 June 2021].
- A. Pavli, M. Theodoridou and H. Maltezou, “Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals,” Vols. S0188-4409, no. 21, 2021.
- C. Huang, L. Huang, Y. Wang, X. Li, L. Ren, X. Gu, L. Kang, L. Guo, M. Liu, X. Zhou, J. Luo, Z. Huang, S. Tu, Y. Zhao, L. Chen, D. Xu, Y. Li, W. Xie, D. Cui, L. Shang, G. Fan, J. Xu, G. Wang, Y. Wang, J. Zhong, C. Wang and J. Wang, “6-month consequences of COVID -19 inpatients discharged from hospital: a cohort study,” Lancet, vol. 397, no. 10270, pp. 220-232, 2021.
- V. Puntmann, M. Careri, I. Wieters, M. Fahim, C. Arendt, J. Hoffmann, A. Shchendrygina, F. Escher, M. Vasa-Nicotera, A. Zeiher, M. Vehreschild and E. Nagel, “Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID -19),” JAMA Cardiology, vol. 1:5, no. 11, pp. 1265-1273, 2020.
- T. Greenhalgh, M. Knight, C. A’Court, M. Buxton and L. Husain, “Management of post-acute Covid -19 in primary care,” BMJ, vol. 370:m3026, 2020.
- J. Shah, S. Kumar and A. Patel, “Myocarditis and Pericarditis in Patients with COVID -19,” Heart Views, vol. 21, no. 3, pp. 209-214, 2020.