Understanding Long COVID: Heart Muscle Damage Needs to Be Spotted Early

Fatigue, shortness of breath, chest pain: one year after the emergence of COVID‑19, there is increasing evidence that patients who have recovered from an acute COVID-19 infection may still struggle with health issues several weeks after becoming infected. This condition has been called post-COVID-19 syndrome or “long COVID.” Doctors are working to better understand this condition, supported by Bayer’s Radiology team. 

Among them is cardiologist Dr. Valentina Püntmann at University Hospital Frankfurt. Through analysis of magnetic resonance imaging (MRI) scans, Püntmann and her team examine the hearts of recovering COVID-19 patients. 


Dr. Püntmann, your study last year was among the first to provide evidence that a COVID-19 infection can damage the heart. 

Yes, we reported the results of our first 100 COVID-19 patients, scanned around 10 weeks after they tested positive for the virus. These patients volunteered to have a cardiac scan as part of the research and not because of heart-related issues. By using cardiac MRI with a gadolinium contrast agent, we identified evidence of heart abnormalities in three out of every four patients, regardless of how sick they had been during their COVID-19 infection or their preexisting conditions. 


What do the changes look like on the MRI scan?

Cardiac MRI is a very sensitive way to diagnose the involvement of the heart. The changes we detected included at least one of the following: either impaired pumping function of the heart, myocardial inflammation or fibrosis, the presence of heart scarring or inflammation of the heart’s lining. Mostly, the type of cardiac damage we found was inflammation of the heart muscle, also known as myocarditis, as well as of the heart’s lining, known as pericarditis. Myocarditis is not easy to identify because the symptoms are usually mild. Many patients have consulted other physicians before me, unfortunately with no successful diagnosis of their condition. Often the heart’s ability to pump is mildly impaired and may cause irregular heartbeats. However, it can develop into a more serious condition, potentially leading to long-term heart problems and even heart failure. 


What did you do with these initial findings?

To better understand these findings, we extended our study and to date have included close to 500 patients aged between 18 and 60 to further investigate the impact of COVID-19 on the heart. We also perform follow-up scans to understand the evolution of the symptoms and changes in the heart. We learned that many patients had symptoms of long COVID – such as breathlessness on minimal exertion or deep, burning chest pains – that persist six months and longer after the original infection. Having a cardiac scan helped many to better understand their symptoms and adjust their lifestyles, for example by exercising slightly less for a few months or reducing their working hours.


How can a person find out if long COVID conditions are affecting their heart? What are the symptoms?

Long COVID may present as a wide range of symptoms, such as exercise intolerance, palpitations and atypical sharp and burning yet persistent chest pain. Although many have trouble breathing, post-COVID patients do not have advanced features of heart failure, such as swollen legs. The patients we see were usually very healthy and fit before becoming infected. Some exercised regularly or were even athletes. Although they struggle to achieve their previous level of fitness, they also compensate very well and do not develop pronounced symptoms. Those who were less fit or had light hypertension have more pronounced symptoms of post-COVID, including tiredness, fatigue and a fast-beating or pounding heart, also known as palpitations. In some cases, the symptoms are so strong that they impede the patients’ ability to perform routine daily tasks and impact their quality of life even months after the infection.


What can patients do to support their recovery when they have signs of heart muscle damage?

One of the most important measures is to stop excessively exercising. The more patients push to try to get fitter, the more they provoke the symptoms. It is important to recognize that the injured heart needs time to heal. Most patients do get better after three to six months, although it can sometimes even take a year. 


Many European countries are easing coronavirus precautionary measures. Is long COVID still an underestimated risk?

It’s important to generate awareness about long COVID and the potential types of post-COVID conditions that may affect organs like the heart. Protecting ourselves – even if we are vaccinated – will continue to be essential because the virus is still around, even though the acute course of infections might be much milder thanks to vaccination. It is unclear to what extent they prevent long-term complications. 
Until now, the focus of the pandemic has been on preventing the severe course of acute disease and deaths in elderly generations, but it is crucial to remember that most long COVID patients are younger adults, so their risk of incapacity should not be forgotten. There is now also data suggesting that children also suffer from similar symptoms. 


Can you share some observations about the patient characteristics in this population?

The majority of children do not seem to develop symptoms when infected with the coronavirus, or their symptoms are very mild. However, data from my U.K. and Spanish colleagues suggests that some of the children experience similar long-term symptoms post-COVID, many months after the initial infection. We also have very little systematic knowledge about the effects in adolescents.


What do you think are the mid- to long-term consequences of long COVID in general for our collective health and health care systems?

Vaccines are the key to combating the extent of COVID-19 , and we have been incredibly fortunate to have seen their development in such a short span of time. But it’s not over yet and the situation is developing at a different pace worldwide. Coronavirus-related heart involvement may just become one of several possible diagnoses that doctors need to consider in the future. It is possible that the potential cardiac impact of an infection will create long-term health care challenges in the coming years. We also think that there is an opportunity to act and actually develop measures to prevent this. This is where MRI comes into play. The imaging process helps to detect the problem at an early stage and to monitor the course of the disease. Recognizing early signs of developing heart failure can facilitate the use of existing heart failure medications early and speed up patients’ recovery. At the same time, new treatment strategies are needed to prevent long-lasting damage.


What needs to happen to react to this relatively new disease?

Clearly, we are all providing small pieces of a huge whole, but together the picture is becoming clearer. We need many more clinical studies that deliver actionable evidence to be able to help patients. I am really impressed by all the efforts undertaken by scientists around the world to drive a better understanding of COVID-19 and the potential long-term consequences of this infection. This spirit needs to continue. 

About Dr. Valentina Püntmann

Dr. Valentina O. Puntmann, MD, PhD, is Associated Professor at the Division of Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt. She is a board-certified cardiologist, clinical pharmacologist and physician. Dr. Puntmann holds accreditations in multimodality cardiovascular imaging. Her research focuses on biomarker and drug discovery to guide prevention and treatment of early heart disease. Her expert topics include non-ischemic inflammatory cardiomyopathies, including cardio-oncology, cardio-HIV and cardio-rheumatology, and more recently, COVID-19-related heart involvement. Puntmann has authored over 100 papers andgiven more than 500 conference presentations. She serves as a member of the EuroCMR Board of Examiners and is a former member of the SCMR Clinical Trial Committee. Dr. Puntmann directs Goethe CVI® Academy at University Hospital Frankfurt in Germany.

Dr. Valentina Püntmann