Reviewed by Giuseppe Biondi-Zoccai

Introduction

As the acute phase of the COVID-19 pandemic recedes, attention is increasingly shifting toward its long-term cardiovascular consequences. While early public health efforts appropriately focused on respiratory complications and mortality reduction, it has become clear that SARS-CoV-2 infection exerts a sustained and clinically meaningful cardiovascular burden. Cardiovascular complications now represent a major contributor to post-COVID morbidity, impaired functional status, and excess long-term mortality, even among individuals who experienced mild initial illness. COVID-19 should therefore be regarded not as a transient infectious insult, but also as a chronic cardiovascular disease modifier with implications that extend well beyond viral clearance.

COVID-19 and the Cardiovascular System

COVID-19 has consistently demonstrated its capacity to act as a potent cardiovascular stressor. Acute infection is associated with systemic inflammation, endothelial dysfunction, thromboembolic events, arrhythmias, myocarditis, myocardial infarction, and heart failure. Importantly, these pathophysiological processes may persist or evolve after recovery from the acute illness. A substantial proportion of patients develop ongoing cardiovascular symptoms as part of Long COVID, including chest pain, dyspnoea, palpitations, fatigue, and orthostatic intolerance¹. Observational data suggest that 10-20% of individuals with Long COVID report cardiovascular manifestations, translating into a considerable and growing population with unmet clinical needs.

A Timely European Consensus

In this context, the recent clinical consensus statement published in the European Journal of Preventive Cardiology² by the European Association of Preventive Cardiology, together with other ESC associations, represents a timely and authoritative contribution. This multidisciplinary document provides comprehensive guidance on cardiovascular prevention and management across the full COVID-19 continuum, encompassing acute infection, recovery, Long COVID, reinfection, and post-vaccination cardiovascular events. Crucially, it bridges the gap between rapidly emerging observational evidence and pragmatic clinical care, offering clinicians a structured framework in an area characterised by uncertainty and heterogeneity.

Prevention as a Central Strategy

A key strength of the consensus statement is its emphasis on early and sustained cardiovascular prevention following SARS-CoV-2 infection. Patient education is positioned as a foundational intervention, empowering individuals to recognise delayed cardiovascular symptoms and seek timely medical review. This represents an important shift in clinical culture, as many patients remain unaware that cardiovascular disease may develop weeks or months after infection. The document reinforces the importance of optimising traditional cardiovascular risk factors, including blood pressure, glycaemic control, lipid management, smoking cessation, healthy nutrition, weight optimisation, and tailored physical activity^3,4. Notably, it advises against routine prophylactic antiplatelet or anticoagulant therapy in the absence of established indications, reflecting a balanced and evidence-based approach.

Vaccination and Cardiovascular Risk Reduction

Vaccination is reaffirmed as a cornerstone of cardiovascular prevention. Beyond reducing acute disease severity and mortality, vaccination significantly lowers the risk of Long COVID⁵ and COVID-19–related cardiovascular complications. The consensus also provides pragmatic guidance on rare vaccine-associated cardiovascular events, emphasising early recognition, appropriate investigation, and shared decision-making. Importantly, it highlights that the cardiovascular benefits of vaccination overwhelmingly outweigh potential risks for the vast majority of patients.

Cardiac Rehabilitation in Long COVID

One of the most impactful recommendations within the document is the strong endorsement of cardiac rehabilitation following COVID-19. Rehabilitation is framed not as an optional adjunct, but as a central therapeutic pillar for patients with overt cardiovascular complications as well as those with persistent fatigue, exercise intolerance, or autonomic dysfunction. The consensus advocates for personalised, multidisciplinary programmes incorporating low-intensity exercise training, education, psychological support, and optimisation of medical therapy. Importantly, it recognises the need for symptom-guided progression to avoid post-exertional symptom exacerbation, a hallmark of Long COVID⁶. The integration of digital health tools and hybrid care models, leveraging also artificial intelligence as appropriate, is also highlighted as a means to improve accessibility and long-term engagement.

Clinical Assessment and Ongoing Uncertainty

While acknowledging limitations in the current evidence base, the consensus offers pragmatic guidance for the investigation and management of cardiovascular manifestations of Long COVID. A symptom-driven diagnostic approach aligned with established ESC guidelines is recommended to identify treatable pathology such as heart failure, arrhythmias, myocarditis, microvascular ischaemia, and autonomic dysfunction. Importantly, the document cautions against both excessive investigation and therapeutic nihilism, advocating a balanced approach that ensures pathology is neither overlooked nor over-medicalised.

Figure 1: A tree diagram highlighting non-invasive tests in patients presenting with symptoms or conditions that could be attributed to Long COVID. Reproduced with permission from ².

Conclusion: A New Paradigm for Long-Term Cardiovascular Management After COVID-19

This consensus statement marks a pivotal moment in cardiovascular medicine. It signals a transition from crisis response to long-term cardiovascular stewardship, reframing COVID-19 as a chronic cardiovascular risk factor that demands sustained preventive strategies. By placing prevention, vaccination, and rehabilitation at the centre of care, it offers a clear roadmap to improving outcomes, restoring functional capacity, and enhancing quality of life for millions of COVID-19 survivors. As research continues to evolve, this document provides a robust foundation upon which future evidence-based practice and guideline development can build.