Red Flags in Long Covid

Updated: Oct 22, 2021

The content for this blog is taken from Dr Harsha Master's talk when she spoke to General Practitioner's gathered at the Royal College of General Practitioners annual conference 2021. Dr Master is the GP lead in COVID assessment and rehabilitation, Hertfordshire Community NHS Trust, one of the first Long Covid clinics to be set up.

Please feel free to share widely with any health care professional dealing with Long Covid patients.

From the article "Respiratory, Cardiac, and Neurological Red Flags for Long COVID" written by Becky McCall, October 18, 2021.

Watch for the big three red flags in patients with long COVID

  1. Cardiac - ischaemia, tachyarrhythmia, myocarditis and pericarditis

  2. Neurological - Transient Ischaemic Attack and stroke

  3. Respiratory - pulmonary embolism

"Don't just go on observations and parameters, if the patient isn't improving then send them in along the usual pathways such as hospital admission or referral to a rapid-access chest pain clinic," said Dr Master, sharing her clinic's experience of more than 800 long COVID cases. "We don't always know what is going on, and acute pathology must be ruled out first."

She related the story of one patient, a woman of 50, who was previously fit and well, with ongoing COVID symptoms, who went to A&E three times. "Her resting oxygen saturations were normal, her pulse was normal, her ECG was normal, her D-Dimer was normal. On her third presentation [at A&E she was found to have a pulmonary embolism, 3 months down the line."

(Dr Kerry - this is the experience of myself with a respiratory consultant who repeatedly ignored my angina-type chest pain by "putting it to one side for the moment" and discharging me. It was subsequently found to be microvascular angina. It's also the experience of my partner who was told on 3 separate occasions by his GP that the chest pain and tachycardia he was experiencing was "just Long Covid" and he finally got a diagnosis of Myocarditis. We both had to seek private doctors who understood the effects of Acute Covid-19 and BELIEVED our symptoms).

The East and North Hertfordshire clinic was one of the first to see ex-hospital as well as non-hospitalised COVID patients. The service went live in August 2020.

Dr Master described her approach to treating patients upon presentation at the clinic. "Patients must have been seen by their own GP first. Long COVID is a diagnosis of exclusion, and you have to work the patients up in the same way that you usually would."

With breathlessness, she advised considering respiratory and cardiovascular causes. "Do the BNP (B-type natriuretic peptide). Rule out acute pathology, because malignancy can present very similar to COVID symptoms. Think laterally. Resting oxygen saturations and the D-dimer have not always been found to be reliable post COVID."

The long COVID clinic has physiotherapists, speech and language therapists, occupational therapists, pulmonary rehabilitation, chronic fatigue specialists, a rehabilitation coordinator who coordinates care of patients across the pathway, and Dr Master herself as the COVID rehabilitation GP.

"It seems a combination of medical investigations and rehabilitation works the best," she said. "If you do the rehab without the medication, or vice versa, it does not work well."

(Dr Kerry - a Long Covid clinic actually giving patients medication - wow!!)

Most referrals are from GPs and not many from hospital. "We find 85% are White British, and 15% other Ethnic Minorities. This is seen nationally too. There are more women (66%) than men (34%)," she said, reporting her clinic's data.

As for unusual features, Dr Master has seen patients who were previously fit and well. They usually had a long initial illness of over one week. They had multiple (eight to nine) symptoms presented together, for example, brain fog, chest pain, palpitations, ear, nose and throat symptoms, and anxiety among others. These are clinic observations not data from a trial, she stressed.

"Long-term symptoms seem to echo the initial illness. Fatigue is not just fatigue, it's a post-exertional malaise - a 'boom and bust' phenomenon. These were fit people who can't now walk up the stairs," she explained. "Patients typically have good days and bad days and on the bad they exert and then crash."

Other typical symptoms include autonomic dysfunction (postural tachycardia syndrome, POTS), and features of MAST Cell Activation Syndrome (MCAS), new-onset food intolerance, diarrhoea. "ENT symptoms, for example mild sinusitis is often remarkably worse since COVID in these patients," Dr Master pointed out.

Among long COVID patients who were hospitalised for COVID, most were over 50, male, more were African, Caribbean, and Asian, and they already had a propensity towards having cardiovascular disease, diabetes, and hypertension. They were also more likely to have had adverse sequelae of the acute illness, said Dr Master. In contrast, those not hospitalised for COVID were more often between 20-60 years, female, White, previously fit and well and had multiple organ syndromes.

She outlined some theories behind long COVID, although she admitted it was observational and from her clinic only. "It's multi-system – heart, brain, lungs, liver. It's thought to be an exaggerated immune response causing inflammation and autonomic dysregulation. There's also a possible mechanism of endotheliopathy and immunothrombosis, and a possible MCAS leading to hyper inflammatory response."

In terms of barriers to recovery, Dr Master said there was often a lapsing-remitting pattern, with stress, anxiety, sleep disruption, overwork, over exertion, and poor gut health at play.


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