Long Covid: chest pain

Chest pain after Covid-19 infection affects up to 22% of patients, but when should GPs investigate? By Dr Kiran Desai, Dr Rebecca Bamford and Dr Adam Ainley

Chest pain has been found to affect up to 22% of patients two months after acute Covid-19.¹ In a large study of around 2,500 patients, chest pain affected 5% of patients six months after discharge from hospital with Covid-19.² In a cohort study of 100 patients, of whom 17% had atypical chest pain and 20% had palpitations two to three months after acute Covid-19, cardiac magnetic resonance (CMR) imaging revealed ongoing cardiac involvement in 78% of patients and signs of myocarditis or myocardial inflammation in 60%.³ Only one-third of patients had been hospitalised. 

Could the chest pain be unrelated to Covid-19 infection?

It is important to exclude alternative diagnoses, particularly when chest pain is the sole symptom of presentation. To ascertain whether the pain is related to Covid, explore the course of the patient’s acute Covid infection, including the type and duration of symptoms and any hospital admissions or complications. 

Patients should be referred urgently to acute services if they have acute cardiac chest pain or signs of severe lung
disease, particularly if this is the only symptom. Patients with long Covid rarely present with chest pain as a single symptom.⁴ 

New or deteriorating symptoms must be investigated as they could be indicative of delayed effects of Covid-19.¹

Specific, treatable causes of chest pain related to long Covid include musculoskeletal chest pain, respiratory complications like pneumonia, pneumothorax or pulmonary embolism, and cardiovascular complications like postviral myocarditis or pericarditis, or pericardial effusions. 

Assessment

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

Investigation and management

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
• Troponin
• Creatine kinase
• D-dimer
• Brain natriuretic peptide
• Twelve-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. Treatment of Covid-19-related pericarditis is similar to the recommended treatments for viral pericarditis – NSAIDs, steroids and colchicine.⁶ Treatment of myocarditis is supportive, and dependent on complications such as cardiogenic shock or arrhythmias.⁶

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-associated PE. 

Musculoskeletal chest pain can be managed in primary care with analgesia. Chest pain as a sole complaint is more likely to be secondary to a specific cardiac complication, as discussed, so referral directly to cardiology may be more appropriate.

Referral to a long Covid service may be necessary where an alternate non-Covid-related cause (such as angina, acute myocardial infarction, pulmonary embolism, pneumothorax, trauma, acid reflux) or known acute Covid complications such as pulmonary embolism have been excluded. This is especially suitable when the symptoms – including the chest pain – are affecting the patient’s quality of life despite adequate intervention in the community or there is uncertainty despite exclusion of acute causes and the pain exists as part of a cluster of recognised post-Covid syndrome symptoms. 

Further multidisciplinary assessment may be required to exclude known post-Covid causes of pain including myocarditis, costochondritis, myalgia and musculoskeletal pain related to muscle fatigue, spasm or persistent cough, or psychological causes. 

The long Covid centre’s team would assess the patient, and may refer them for further imaging, including CT scans and echocardiograms, or to cardiology for more detailed investigations such as CMR. 

Further management may also include the use of directed physiotherapy, fatigue management and psychological support where appropriate. 

Dr Kiran Desai is a senior clinical fellow in respiratory medicine, Dr Rebecca Bamford is a specialist trainee registrar in respiratory medicine and Dr Adam Ainley is a consultant respiratory physician, all in Barking, Essex

References 

1. Pavli A et al, Post-Covid syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals, Archives of Medical Research 2021; 52(6):575-581.
2. Huang C et al. Six-month consequences of Covid-19 in patients discharged from hospital: a cohort study. Lancet 2021;397:220-232.  
3. Puntmann V et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from Coronavirus disease 2019 (Covid-19). JAMA Cardiology 2020;5(11):1265-1273.
4. NICE. Covid-19 rapid guideline: managing the long-term effects of Covid-19, NG188. London: NICE, 2020.  
5. Greenhalgh T et al. Management of post-acute covid-19 in primary care. BMJ 2020;11;370:m3026.
6. Shah J et al. Myocarditis and pericarditis in patients with Covid-19. Heart Views 2020;21(3):209-214.