 What's up guys? This is Dr. Ali Hader, International Cardiology. Thank you for checking into the channel. If you have not already, please subscribe and hit the bell notification so you don't miss any future videos. I'm on vacation this week. As you can see, not at home, but I wanted to drop a quick video about a COVID topic that's been discussed a lot recently, and that is lingering chronic effects of patients who have already had COVID. Here's two scenarios. A 30-year-old male who recovered from COVID has ongoing symptoms rapid heartbeat and heart palpitations every time he climbs stairs, fatigue, and lingering mild shortness of breath that's not limiting from daily activities, but he's not really able to exercise. Another case is a 40-year-old something healthcare worker, and she has also recovered from COVID as ongoing symptoms of fatigue, muscle aches, and this brain fog that's making her sort of not as crisp as she used to be. Both of these patients had COVID, but weeks to even months ago and none of them were even in the ICU. Now, there are plenty of folks who get mild case of COVID, recover completely, and get back to normal. However, we're seeing more and more of these people who are having these sort of chronic lingering symptoms that are preventing them from getting back to them normal selves. This is a real phenomenon, and I want to dive into this a little deeper today. Now, when we're evaluating a global pandemic, the two most important things we look at are the rate of new infections and the death rate. However, it's not all about mortality and death rate. We also have to take into account morbidity, quality of life of patients who have recovered from COVID, but have ongoing symptoms, problems, and sometimes even a lifelong disability. Since we've been dealing with this infection now for well over half a year, we're seeing more and more and learning more about these situations. Again, there's certainly a variation of these lingering symptoms, some of them may actually resolve completely, but we really don't have a sense of what the long-term effects of having a COVID infection is as yet. Now, if someone is super sick with COVID, who ended up in the ICU, surviving an ICU stay, especially if you're in there for weeks, is a huge victory. In fact, a lot of hospitals were even having mini celebrations anytime we were able to discharge a COVID positive patient. However, the flip side of the coin is, what is the quality of life cost of that stay for that particular patient? Meaning, what are the long-term effects, symptoms, and limitations that are going to be seen by that particular patient? Now, that is not something that's evaluated or counted in these metrics that we see, but it's super important to think about. Now, there's obviously a huge variation of the type of COVID-19 infection you're going to get if you get SARS-CoV-2 virus, and that could be a very mild to asymptomatic infection to somebody sick enough to need in the ICU or potentially even dying. I want to focus on two types of patients, both of them hospitalized patients, but the patients who are in the ICU and those who did not require the ICU, because if you're hospitalized, that gives a sense that you have a significant enough infection and you are more likely to have sort of these lingering chronic effects. So, let's look at the patients who are not sick enough to be in the ICU but required hospitalization. These are patients who may need oxygen support, intermediate fluids, and closer monitoring to make sure that they didn't decompensate and become one of the very sick ones. Now, there's a lot of different symptoms that I'm hearing from patients who have recovered from COVID, again, weeks to months ago. Some of these could include fatigue, which is pretty common, shortness of breath that is still there, very mild, but still not breathing normally, muscle aches, just a lack of the ability to exercise. That's probably the most common thing I see. I'm also seeing a lot of patients who are getting heart palpitations or rapid heartbeats. We're doing a lot of Holter models in these folks and we're seeing these are not really arrhythmia. Patients definitely are getting an exaggerated heart response, but it's all sinus tachycardia. Now, a lot of these reports are anecdotal from physicians like myself, sharing it with other physicians. However, we do have some data that's been published that is actually tracking this and we have ongoing trials that are going to be following a lot of these COVID patients now for a year or so down the line. Now, one article in JAMA looked at 146 patients post-COVID after discharge from the hospital. They looked at both ICU and non-ISU patients. They evaluated a lot of different lingering symptoms and 50% of them said they had ongoing fatigue, dyspnea, cough, chest pain, and a slew of other symptoms, as you can see here in this chart. Again, there's several other longitudinal studies that are evaluating this. There's even an app that is a study that's gathering information from an app that COVID patients who have recovered can download and track their symptoms and report what they're feeling. So, it'll be really interesting to see what we see down the line in terms of months to even years post infection and what if any lingering symptoms are still present. Now, let's look at some of the sicker patients, specifically those who were in the ICU. This is a different breed of patient. They're way sicker. These are the ones who get this hyper inflammatory response or the cytokine surge that we talk about and they have significant lung injury often requiring mechanical ventilation or a very, very high flow oxygen to support the bodies and the lungs to be able to function and oxygenate the blood. They also have concomitant multi-organ dysfunction meaning they have injury to the kidneys, sometimes the heart, sometimes they can have clotting problems which has been reported quite a bit, so overall much sicker and a much more prolonged hospital stay. Now, talking to my pulmonary colleagues, they're seeing a lot of these very sick patients who managed to recover in follow-up and we're seeing various types of ongoing symptoms. Most commonly, of course, shortness of breath from probably scarring that we're seeing in the lungs. People are requiring more oxygen to support even at home after they've recovered, sometimes intermittently, and some patients even long-term. We're seeing paranumonic effusions or fluid in the linings of the lungs that are a result of the inflammation and the infection that they get from the viral pneumonia and just overall sort of, you know, deconditioning and decompensated physical status of these folks. How much of this is going to be long-term and permanent? Unclear, but I suspect there's going to be very different classes of patients, some that may have oxygen requirements for very long periods of time and some that may eventually recover. Now, focusing on ICU patients, aside from COVID-specific effects, these patients can also get something called post-ICU syndrome. Now, this is a well-established syndrome that occurs in patients who can be in the ICU usually for some severe infection or sepsis and longer the ICU stay is, the more likely they're to develop this phenomena. This is sort of like a post-traumatic syndrome that occurs from an ICU stay. Now, the Society of Critical Care Medicine divides this post-ICU syndrome into two sort of categories. One is the cognitive brain effects that occur and the other is sort of the muscle weakness and neuromuscular effects that occur. On the cognitive side of things, these patients experience a lot of behavioral health and mental health issues such as anxiety, depression, there can be a lot of confusion and memory loss, there can be, again, this significant brain fog but at a point that it affects your functionality and, again, Frank PTSD as well. The second part of it is this sort of critical illness, neuropathy or muscle weakness that can occur during the ICU stay and kind of lingers along after the ICU stay even when they recover. This can lead to muscle weakness, fatigue and just overall poor functional status compared to what they were like before the stay. So, both of these issues compromise quality of life for the patients quite significantly and, again, especially those who have been in the hospital in the ICU for a prolonged period of time. Again, these aren't COVID specific problems but clearly we're going to be seeing a lot of this out there since all these folks who had COVID did require a lot of ICU stay. Now, the reason why we get these lingering symptoms and effects in these patients even the ones who weren't in the ICU are super sick still remains a little bit unclear. Now, we do know from autopsy studies that viral particles have been found in other organs. There has been evidence of the virus in the brain. There's been evidence of the virus in the heart. Now, the clinical significance of this is unclear. Could that be related to why they have these lingering effects because there's these viral particles that's hanging around in different organ systems or maybe it's just a secondary immune response in the inflammatory response that's lingering or perhaps there is some more short-term damage that has occurred from the virus the body needs to heal. It's unclear if the presence of the virus in those brain cells they found means anything. However, what they did found in most of these autopsy studies were patients that had significant hypoxic injury to brain cells meaning brain cells were injured because of lack of oxygen. Now, this obviously could have occurred because patients who get the infection have super low oxygen levels because of the lungs and this can reduce the oxygen in the blood therefore reduce the oxygen going to the brain resulting in injury. Another mechanism is that patients with severe COVID do get a lot of blood clots. Microscopic blood vessels can clot over as well as larger blood vessels and they found evidence of these micro thrombi in brain blood vessels which could subsequently lead to low oxygen and again further brain injuries so it's sort of like they're having small strokes scattered throughout the brain but it's due to lack of oxygen. This certainly could explain some of these lingering neurological effects that take a long time to go away but again up till now a lot of this is conjecture and a lot of this is theory. There was also a recent paper suggesting that patients who recovered from SARS-CoV-2 had evidence of ongoing myocardial inflammation and a large percentage of patients. However, that paper seems to have some biostatistical issues like a lot of research coming out these days with the COVID-19 era. There's been a lot of missteps a lot of errors so I'm not even going to put a lot of weight into that paper until they bring out a correction but if it's true and there is evidence of inflammation of myocardial cells again this could tie into some of these long-term symptoms that we're experiencing especially the cardiac ones. So I think the take one message here is COVID-19 is going to affect a lot of people. Yes a small percentage of those folks are going to die and a large majority of these patients are going to survive but amongst the survivors we may see a wide range of ongoing chronic problems. Some of them may be mild nuisance lingering symptoms that go away in a few months but we may indeed see more chronic problems going on for potentially years to even lifelong. We have to really pay attention to this we have to listen to our patients and there's a lot we need to learn so remember it's not just about death. I'm definitely looking forward to a lot of these longitudinal studies that are happening as we speak and as time goes on we're going to learn more about this and hopefully we'll get some more high quality data out there and it'll give us some insight into learning more about these survivors of COVID and what if anything all these autopsy study data and what not means. So anyway thanks for checking in there's a thunderstorm coming here so I better move inside and hopefully get a new video out to you guys soon please subscribe if you haven't hit the bell notification comment on any other topics you want to hear and we'll talk soon.