For people who have had COVID-19, lingering COVID-19 heart problems can complicate their recovery.

Some of the symptoms common in coronavirus “long-haulers,” such as palpitations, dizziness, chest pain and shortness of breath, may be due to heart problems — or, just from having been ill with COVID-19. How do you tell if your symptoms are heart-related, and what can you expect if they are?

Johns Hopkins cardiologists Wendy Post, M.D., and Nisha Gilotra, M.D., clarify which post-coronavirus symptoms may point to a heart issue, when to call your doctor, and other facts all long-term COVID-19 survivors should know.

Can COVID-19 damage the heart?

Yes: Although COVID-19 is primarily a respiratory or lung disease, the heart can also suffer.

Temporary or lasting damage to heart tissue can be due to several factors:

Lack of oxygen. As the virus causes inflammation and fluid to fill up the air sacs in the lungs, less oxygen can reach the bloodstream. The heart has to work harder to pump blood through the body, which can be dangerous in people with preexisting heart disease. The heart can fail from overwork, or insufficient oxygen can cause cell death and tissue damage in the heart and other organs.

Myocarditis: inflammation of the heart. The coronavirus may infect and damage the heart’s muscle tissue directly, as is possible with other viral infections, including some strains of the flu. The heart may also become damaged and inflamed indirectly by the body’s own immune system response.

Coronavirus infection also affects the inner surfaces of veins and arteries, which can cause blood vessel inflammation, damage to very small vessels and blood clots, all of which can compromise blood flow to the heart or other parts of the body. “Severe COVID-19 is a disease that affects endothelial cells, which form the lining of the blood vessels,” Post says.

Stress cardiomyopathy. Viral infections can cause cardiomyopathy, a heart muscle disorder that affects the heart’s ability to pump blood effectively. When attacked by a virus, the body undergoes stress and releases a surge of chemicals called catecholamines, which can stun the heart. Once the infection resolves, the stressor has ended and the heart can recover.

Cytokine Storm: A Serious Coronavirus Complication

Most serious of all, Gilotra says, is the possibility of the immune system launching an attack on the invading virus that is so severe that it destroys healthy tissues.

When responding to infection with the coronavirus, the body releases a flood of proteins called cytokines that help cells communicate with one another and fight the invaders.

In some people, perhaps due to a genetic difference, this normal defensive event is exaggerated, leaving them vulnerable to a cytokine storm. In a cytokine storm, the immune system response causes inflammation that can overwhelm the body, destroying healthy tissue and damaging organs such as the kidneys, liver and heart.

A cytokine storm and its resulting heart damage can also affect the heart’s rhythm. “Serious ventricular arrhythmias due to a cytokine storm can be catastrophic,” Gilotra says.

A cytokine storm is difficult to survive. Current research is exploring the possible benefit of using immune-suppressing drugs to treat patients with COVID-19 who experience this serious complication.

Heart Rate and COVID-19

After you have had COVID-19, if you are experiencing a rapid heartbeat or palpitations, you should contact your doctor. A temporary increase in heart rate can be caused by a lot of different things, including dehydration. Make sure you are drinking enough fluids, especially if you have a fever. Symptoms of a rapid or irregular heart rhythm may include:

• Feeling your heart beat rapidly or irregularly in your chest (palpitations)
• Feeling lightheaded or dizzy, especially upon standing
• Chest discomfort

How can I tell if I have developed a heart problem after COVID-19?

In some people, heart rates can vary from fast to slow, unrelated to exertion, for no apparent reason. But, Post says, shortness of breath, chest pain or palpitations after having COVID-19 is a common complaint. “Any of these problems could be related to the heart, but they could also be due to other factors, including the aftermath of being very ill, prolonged inactivity and spending weeks convalescing in bed.”

Shortness of Breath

“You want to consult a doctor if any of your symptoms are severe, especially shortness of breath,” Post says. She recommends using a commercially available O2 (oxygen) saturation monitor.

“Shortness of breath by itself is not always a sign of a serious problem, but if you have that symptom along with low O2 (below 92%), that is a reason to be concerned.” Sometimes people are short of breath with exertion after COVID-19 because they have been less active for a long time and need to gradually build their fitness level back up.

A diagnosis of heart failure after COVID-19 is rare. But if you have shortness of breath or leg swelling after COVID-19, you should contact your doctor, who may recommend evaluation by a cardiologist if tests indicate you are at risk.

COVID-19 Chest Pain

What about lingering chest pain, another common post-COVID complaint? “Chest pain may be nothing serious, but if you are having severe chest pain, get help, especially if it is persistent or if you are also having nausea, shortness of breath or lightheadedness: These could be symptoms of a heart attack.”

“If you have chest pain when you inhale, you might have lung inflammation. Sudden, severe chest pain could be a blood clot in the lung (pulmonary embolism),” Post says.

People recovering from the coronavirus sometimes show symptoms of a condition known as POTS (postural orthostatic tachycardia syndrome). Researchers are exploring whether or not there is a link.

POTS isn’t directly a cardiac problem, but a neurologic one that affects the part of the nervous system that regulates heart rate and blood flow. The syndrome can cause rapid heartbeats when you stand up, which can lead to brain fog, fatigue, palpitations, lightheadedness and other symptoms.

Can COVID-19 symptoms mimic a heart attack?

Yes. People with COVID-19 can have symptoms similar to those of a heart attack, including chest pain, shortness of breath and changes on their echocardiogram (ultrasound of the heart) or EKG. But often when these patients are given an angiogram, there is no evidence of a major blockage in the heart’s blood vessels, which would indicate a heart attack in progress.

Symptoms of myocarditis can also mimic those of a heart attack. Also, viral infections such as COVID-19 can cause very small blood clots to form, which can block tiny blood vessels and cause pain.

People with signs and symptoms of a heart attack should seek urgent medical attention and not manage these symptoms at home.

When should I see a doctor if I’m having heart symptoms after coronavirus?

Heart Symptom Chart

Family doctor or cardiologist?

If your symptoms are not severe but you want to be checked out, Post says a cardiologist doesn’t need to be your first stop if you’ve never had heart problems before and are not at risk. “For nonemergency post-COVID-19 symptoms, your primary care practitioner can advise you,” she says.

Is a heart attack more likely after COVID-19?

That depends: Post says that “heart attack” has several different forms. A type 1 heart attack, caused by a blood clot blocking one of the heart’s arteries, is rare during or after COVID-19 infection.

“Type 2 heart attacks are more common with COVID-19,” she says. “This heart attack can be caused by increased stress on the heart, such as a fast heartbeat, low blood oxygen levels or anemia, because the heart muscle isn’t getting enough oxygen delivered in the blood in order do this extra work. We have seen this in people with acute coronavirus disease, but it is less common in those who have survived the illness.”

“Blood tests have shown that during COVID-19, some people have elevated levels of a substance called troponin in their blood, along with EKG changes and chest pain.” Elevated troponin levels are a sign of damaged heart tissue. Sometimes this is from a heart attack. This is less commonly seen after COVID-19.

“During acute COVID-19, elevated troponin levels with an abnormal EKG are linked to higher mortality, but not in patients with a normal EKG,” Post says.

What about heart problems in children after COVID-19?

In general, children who get sick with the coronavirus do not have serious problems as often as adults do. An uncommon but serious complication of COVID-19 called multisystem inflammatory syndrome in children, or MIS-C, can cause serious heart damage, cardiogenic shock or death.

Some children who survive MIS-C can be left with abnormal heart rhythms and stiffened heart muscle that prevents the heart from relaxing normally and beating properly. MIS-C has some similar characteristics to Kawasaki disease.

Is heart damage caused by COVID-19 permanent?

Post says that if symptoms are due to a cardiac cause, recovery depends on the severity of injury. “Very few people have a severe heart attack, such as an acute myocardial infarction, or MI, due to COVID-19,” she says.

Still, heart imaging can reveal minor changes in the heart muscle of some COVID-19 survivors. Post notes that some studies on athletes recovering from the coronavirus have shown some scarring, but stresses that some of these studies did not compare these results with those who had not had COVID-19. How long these minor changes persist — and how they affect heart health — are not yet known. Experts are developing protocols and recommendations for which athletes should get cardiac testing before returning to play.

COVID-19 can also affect the strength of the heart pumping, Post says, but subtle abnormalities in heart pumping are not likely to cause people problems.

A person recovering from COVID-19 may benefit from physical therapy, breathing exercises and, most of all, time. Post advises anyone recovering from COVID-19 should expect a gradual course of recovery, and should not expect a rapid return to their normal activity levels.

Can having COVID-19 make an existing heart condition worse?

“A heart condition could be exacerbated by severe COVID, but not likely after mild or asymptomatic cases,” Post says. “But the effects of the coronavirus on preexisting heart disease are not yet known.”

Can heart problems show up long after COVID-19 recovery?

If you have had COVID-19, recovered and feel all right now, should you worry? Are heart problems likely to show up later on?

Post emphasizes that many of these questions do not have clear answers yet. SARS-CoV-2 was isolated in 2019, and a large number of COVID-19 survivors have only been recovering since 2020. “It is hard to know exactly how the disease will affect people’s hearts long term, and this is just one area of intense concern among researchers,” she says.