AHA scientific statement offers recommendations on exercise for ‘long COVID’

The American Heart Association provided recommendations on exercise training for patients with postacute sequelae of SARS-CoV-2 (PASC), also known as “long COVID,” in a recent scientific statement.

The statement, published by Circulation on June 30, notes that the condition may affect 10% to 25% of patients diagnosed with COVID-19 and has been reported to have more than 100 related symptoms. However, almost all patients report severe fatigue, orthostatic intolerance, shortness of breath, and reductions in exercise tolerance.

“Although multiple factors contribute to development of this syndrome, there is accumulating evidence that cardiovascular deconditioning is a central component of the pathophysiology. This deconditioning results from a relative reduction in physical activity in the setting of the index infection and its quarantine/confinement and leads to cardiac atrophy, a reduction in ventricular distensibility, and steepening of the Frank-Starling curve,” the statement said.

The statement defines the condition, discusses contributory mechanisms, and offers guidance on tailoring exercise for patients with PASC. “First, the exercise protocol must incorporate low-duration, low-intensity exercise early to minimize or avoid the risk of postexertional malaise,” it said.

The other main consideration is the type of exercise; upright exercises, such as running, may not be tolerated at first, according to the statement. “To accommodate orthostatic intolerance, exercises that are conducted in a recumbent/semirecumbent position with the impact of gravity on the cardiovascular system minimized must be considered,” the authors said, suggesting rowing and recumbent or semirecumbent cycling as options.

The statement also discusses return to play for athletes who have had COVID-19 or PASC. “Only the presence of cardiopulmonary symptoms, including chest tightness/pain, dyspnea, palpitations, or lightheadedness/syncope, was predictive of myocardial involvement after COVID-19 infection,” and thus, only athletes with these symptoms require cardiac evaluation, it said. The statement also discusses disparities in access to care and knowledge gaps about the condition.

“An exercise prescription specifically tailored to the patient with cardiovascular deconditioning may be an effective method of improving symptom severity. A shared decision-making process should be incorporated to determine the best methods for incorporating an exercise program into patient management and diagnostic/clinical evaluation for determining the optimal timing for [return to play] among affected athletes,” it concluded.