Long-term cardiovascular sequelae of COVID-19 in patients with pre-existing heart failure: a systematic review

Background: Patients with pre-existing heart failure (HF) are particularly vulnerable to adverse outcomes following coronavirus disease 2019 (COVID-19). Understanding of the long-term cardiovascular sequelae of COVID-19 in this high-risk group is essential to improve post-infection management and outcomes. Methods: A systematic review of PubMed, Scopus, Web of Science, and Embase was conducted to identify peer-reviewed studies published between 2020 and 2025. Eligible studies included adults with a confirmed diagnosis of HF prior to COVID-19 infection and reported cardiovascular outcomes assessed at least 12 weeks after the acute phase. Data were extracted on patient demographics, HF subtype, cardiovascular outcomes, quality of life (QoL), and management approaches. Results: Forty-five studies met the inclusion criteria, encompassing heterogeneous but predominantly high-income country populations across multiple regions and HF phenotypes. COVID-19 was associated with increased HF symptoms, hospital readmissions 28% [95% confidence interval (CI) 24–32%] at 12 months, and mortality 18% (95% CI 15–22%) at ≥ 12 months. Patients with HF with reduced ejection fraction (HFrEF) had a 1.4-fold greater readmission risk than HF with preserved ejection fraction (HFpEF). Mechanistic data implicated persistent myocardial inflammation, endothelial dysfunction, and autonomic dysregulation. Functional capacity declined, with a mean 68-meter reduction in six-minute walk distance (6MWD). Vaccination was associated with a ~40% reduction in mortality and major adverse cardiovascular events (MACE). Discussion: COVID-19 is associated with a sustained cardiovascular burden in individuals with HF, underscoring the importance of long-term surveillance, optimization of guideline-directed medical therapy, and structured rehabilitation. Standardized, prospective studies are needed to elucidate causal mechanisms and refine post-COVID management strategies.