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Autonomic Dysfunction in Post-Acute Sequela of COVID-19
Quick Takes
- Patients with exercise intolerance, tachycardia on minimal activity or positional change, and palpitations as post-acute sequelae of COVID-19 (PASC) often exhibit abnormal orthostatic response to tilt testing, suggesting autonomic dysfunction.
- Almost all (23 of 24) subjects had orthostatic intolerance: four demonstrated postural orthostatic tachycardia syndrome (POTS), 15 had provoked orthostatic intolerance after nitroglycerin, three neurocardiogenic syncope, and one orthostatic hypotension.
- Compared with those with POTS, patients with provoked orthostatic intolerance had significantly earlier improvement of symptoms.
Study Questions:
What are the mechanisms of poor exertional tolerance, tachycardia with minimal activity or positional change, and palpitations in patients with post-acute sequela of COVID-19 (PASC)?
Methods:
Patients with PASC complaining of poor exertional tolerance, tachycardia with minimal activity or positional change, and palpitations underwent head-up tilt table testing.
Results:
Twenty-four patients were included. Tilt test was performed a mean of 6 months after symptom onset; 23 of the 24 had orthostatic intolerance during the tilt test, with four demonstrating postural orthostatic tachycardia syndrome (POTS), 15 provoked orthostatic intolerance after nitroglycerin, three neurocardiogenic syncope, and one orthostatic hypotension. Compared to patients with POTS, patients with provoked orthostatic intolerance after nitroglycerin had significantly earlier improvement of symptoms.
Conclusions:
The authors concluded that orthostatic intolerance on tilt test suggests autonomic dysfunction in nearly all subjects with PASC. Those with provoked orthostatic intolerance after nitroglycerin may be closer to recovery than those having POTS characteristics on tilt test.
Perspective:
Up to one third of patients who recover from COVID-19 complain of persistent symptoms such as fatigue, dyspnea, chest pain, cognitive disturbances, arthralgia, loss of taste and/or smell, and general decline in quality of life. The authors of the present study focused on patients who experience ≥1 cardiovascular sequela (poor exertional tolerance, tachycardia with minimal activity or positional change, or palpitations) ≥3 months after acute COVID-19 infection. All but one of the subjects exhibited orthostatic intolerance during the tilt table test, which is strongly suggestive, although not diagnostic of autonomic dysfunction, as other measures of autonomic dysfunction were not collected. Much more research is needed to guide the care of patients with PASC.
Clinical Topics: Arrhythmias and Clinical EP, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Exercise
Keywords: Ageusia, Arrhythmias, Cardiac, Arthralgia, Cognition, COVID-19, Dyspnea, Exercise, Fatigue, Hypotension, Orthostatic, Nitroglycerin, Orthostatic Intolerance, Postural Orthostatic Tachycardia Syndrome, Quality of Life, Secondary Prevention, Syncope, Vasovagal, Tachycardia, Tilt-Table Test
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