Post-COVID-19 Tachycardia Syndrome: A Distinct Phenotype of Post-Acute COVID-19 Syndrome

Malmö POTS symptom score: Assessing symptom burden in postural orthostatic tachycardia syndrome

BACKGROUND

Postural orthostatic tachycardia syndrome (POTS) is a common cardiovascular autonomic disorder characterized by excessive heart rate (HR) increase on standing and symptoms of orthostatic intolerance, posing significant limitations on functional capacity. No objective tool exists to classify symptom burden in POTS.

METHODS

We conducted a case-control study in 62 POTS patients and 50 healthy controls to compare symptom burden between groups using the newly developed, self-rating, 12-item, Malmö POTS Score (MAPS; 0-10 per item, total range 0-120) based on patients own perception of symptoms through visual analogue scale assessment. We have also explored correlations between symptom severity assessed by MAPS, basic clinical parameters and postural haemodynamic changes.

RESULTS

POTS patients showed significantly higher total MAPS score (78 ± 20 vs. 14 ± 12, p < 0.001), higher baseline systolic blood pressure (BP), diastolic BP and HR (p < 0.001) compared with healthy controls. The most prominent symptoms in POTS were palpitations, fatigue and concentration difficulties. Haemodynamic parameters on standing were significantly correlated with palpitations in POTS after adjustment for age and sex (lower systolic and diastolic BP, and higher HR) (p < 0.001 for all). Orthostatic HR was significantly associated with concentration difficulties and total MAPS score. The optimal cut-point value of MAPS to differentiate POTS and healthy controls was ≥42 (sensitivity, 97%; specificity, 98%).

CONCLUSIONS

Symptom severity, as assessed by MAPS score, is fivefold higher in POTS compared with healthy individuals. The new MAPS score can be useful as a semiquantitative system to assess symptom burden, monitor disease progression and evaluate pre-test likelihood of disease.

Complications after administration of mRNA vaccine against COVID-19 - case report and short review

The pandemic of the disease COVID-19 (COronaVIrus Disease 2019) caused by the SARS-CoV-2 coronavirus (severe acute respiratory syndrome coronavirus 2) resulted in millions of deaths and many patients have chronic consequences after overcoming the acute condition. Several vaccines have been developed in an effort to stop the spread of the virus, but they have potentially serious adverse effects. We present a case report of a patient with acute (myocarditis, exacerbation of bronchial asthma) and long-term (postural orthostatic tachycardia syndrome - POTS) complications after vaccination with the second dose of mRNA vaccine BNT162b2 (Comirnaty®). Treatment consists of regimen measures, numerous pharmacotherapy (metoprolol, ivabradine, corticosteroids, antihistamines, antiphlogistics, bronchodilators) and several nutraceuticals (maritime pine bark extract, quercetin, vitamins, magnesium, phosphatidylcholine). In the discussion, we analyze post-vaccination injury and present a short review of the current literature.

A scoping review of regulatory T cell dynamics in convalescent COVID-19 patients - indications for their potential involvement in the development of Long COVID?

Background

Recovery from coronavirus disease 2019 (COVID-19) can be impaired by the persistence of symptoms or new-onset health complications, commonly referred to as Long COVID. In a subset of patients, Long COVID is associated with immune system perturbations of unknown etiology, which could be related to compromised immunoregulatory mechanisms.

Objective

The objective of this scoping review was to summarize the existing literature regarding the frequency and functionality of Tregs in convalescent COVID-19 patients and to explore indications for their potential involvement in the development of Long COVID.

Design

A systematic search of studies investigating Tregs during COVID-19 convalescence was conducted on MEDLINE (via Pubmed) and Web of Science.

Results

The literature search yielded 17 relevant studies, of which three included a distinct cohort of patients with Long COVID. The reviewed studies suggest that the Treg population of COVID-19 patients can reconstitute quantitatively and functionally during recovery. However, the comparison between recovered and seronegative controls revealed that an infection-induced dysregulation of the Treg compartment can be sustained for at least several months. The small number of studies investigating Tregs in Long COVID allowed no firm conclusions to be drawn about their involvement in the syndrome's etiology. Yet, even almost one year post-infection Long COVID patients exhibit significantly altered proportions of Tregs within the CD4+ T cell population.

Conclusions

Persistent alterations in cell frequency in Long COVID patients indicate that Treg dysregulation might be linked to immune system-associated sequelae. Future studies should aim to address the association of Treg adaptations with different symptom clusters and blood parameters beyond the sole quantification of cell frequencies while adhering to consensualized phenotyping strategies.

Hyperbaric oxygen for treatment of long COVID-19 syndrome (HOT-LoCO): protocol for a randomised, placebo-controlled, double-blind, phase II clinical trial

INTRODUCTION

Long COVID-19, where symptoms persist 12 weeks after the initial SARS-CoV-2-infection, is a substantial problem for individuals and society in the surge of the pandemic. Common symptoms are fatigue, postexertional malaise and cognitive dysfunction. There is currently no effective treatment and the underlying mechanisms are unknown, although several hypotheses exist, with chronic inflammation as a common denominator. In prospective studies, hyperbaric oxygen therapy (HBOT) has been suggested to be effective for the treatment of similar syndromes such as chronic fatigue syndrome and fibromyalgia. A case series has suggested positive effects of HBOT in long COVID-19. This randomised, placebo-controlled clinical trial will explore HBOT as a potential treatment for long COVID-19. The primary objective is to evaluate if HBOT improves health-related quality of life (HRQoL) for patients with long COVID-19 compared with placebo/sham. The main secondary objective is to evaluate whether HBOT improves endothelial function, objective physical performance and short-term HRQoL.

METHODS AND ANALYSIS

A randomised, placebo-controlled, double-blind, phase II clinical trial in 80 previously healthy subjects debilitated due to long COVID-19, with low HRQoL. Clinical data, HRQoL questionnaires, blood samples, objective tests and activity metre data will be collected at baseline. Subjects will be randomised to a maximum of 10 treatments with hyperbaric oxygen or sham treatment over 6 weeks. Assessments for safety and efficacy will be performed at 6, 13, 26 and 52 weeks, with the primary endpoint (physical domains in RAND 36-Item Health Survey) and main secondary endpoints defined at 13 weeks after baseline. Data will be reviewed by an independent data safety monitoring board.

ETHICS AND DISSEMINATION

The trial is approved by the Swedish National Institutional Review Board (2021-02634) and the Swedish Medical Products Agency (5.1-2020-36673). Positive, negative and inconclusive results will be published in peer-reviewed scientific journals with open access.

TRIAL REGISTRATION NUMBER

NCT04842448.

Postural orthostatic tachycardia syndrome as a sequela of COVID-19

Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.

Post-COVID Phenotypic Manifestations are Associated with New-Onset Psychiatric Disease: Findings from the NIH N3C and RECOVER Studies

Acute COVID-19 infection can be followed by diverse clinical manifestations referred to as Post Acute Sequelae of SARS-CoV2 Infection (PASC). Studies have shown an increased risk of being diagnosed with new-onset psychiatric disease following a diagnosis of acute COVID-19. However, it was unclear whether non-psychiatric PASC-associated manifestations (PASC-AMs) are associated with an increased risk of new-onset psychiatric disease following COVID-19. A retrospective EHR cohort study of 1,603,767 individuals with acute COVID-19 was performed to evaluate whether non-psychiatric PASC-AMs are associated with new-onset psychiatric disease. Data were obtained from the National COVID Cohort Collaborative (N3C), which has EHR data from 65 clinical organizations. EHR codes were mapped to 151 non-psychiatric PASC-AMs recorded 28-120 days following SARS-CoV-2 diagnosis and before diagnosis of new-onset psychiatric disease. Association of newly diagnosed psychiatric disease with age, sex, race, pre-existing comorbidities, and PASC-AMs in seven categories was assessed by logistic regression. There was a significant association between six categories and newly diagnosed anxiety, mood, and psychotic disorders, with odds ratios highest for cardiovascular (1.35, 1.27-1.42) PASC-AMs. Secondary analysis revealed that the proportions of 95 individual clinical features significantly differed between patients diagnosed with different psychiatric disorders. Our study provides evidence for association between non-psychiatric PASC-AMs and the incidence of newly diagnosed psychiatric disease. Significant associations were found for features related to multiple organ systems. This information could prove useful in understanding risk stratification for new-onset psychiatric disease following COVID-19. Prospective studies are needed to corroborate these findings.

FUNDING

NCATS U24 TR002306.

Safety after BBIBP-CorV (Sinopharm) COVID-19 Vaccine in Adolescents Aged 10-17 Years in Thailand

Coronavirus disease 2019 affected child health and impacted learning because of the resulting onsite school closures. This prospective cohort study included children aged 10-17 who received two 4 µg doses of BBIBP-CorV administered intramuscularly 21-28 days apart. To assess vaccine safety, 36,808 participants were then followed with paper- and web-based online questionnaire surveys that captured local and systemic reactogenicities following vaccine administration on days 1, 7, and 30. Among participants, 76% (27,880) reported reactogenicity within the first 24 h and 7 days following the first dose. Half (51.41%) of participants experienced pain at the injection site; the majority of cases were mild in severity. Injection site tenderness (37.93%) was another common local reaction. Fatigue (37.89%), myalgia (33.56%), and headache (26.76%) were the most common systemic reactions. On days 2-7 after the first dose, 25.85% of participants experienced adverse reactions. Following the second dose, reactogenicity was 7.6% and 1.09% within 24 h and between days 2-7. The majority of reactions were of mild to moderate severity. We report that two doses of the BBIBP-CorV caused mild to moderate side effects in adolescents in Thailand. The findings confirm the vaccine's safety profile in this age group.

Pathophysiology of Post-COVID syndromes: a new perspective

Most COVID-19 patients recovered with low mortality; however, some patients experienced long-term symptoms described as “long-COVID” or “Post-COVID syndrome” (PCS). Patients may have persisting symptoms for weeks after acute SARS-CoV-2 infection, including dyspnea, fatigue, myalgia, insomnia, cognitive and olfactory disorders. These symptoms may last for months in some patients. PCS may progress in association with the development of mast cell activation syndrome (MCAS), which is a distinct kind of mast cell activation disorder, characterized by hyper-activation of mast cells with inappropriate and excessive release of chemical mediators. COVID-19 survivors, mainly women, and patients with persistent severe fatigue for 10 weeks after recovery with a history of neuropsychiatric disorders are more prone to develop PCS. High D-dimer levels and blood urea nitrogen were observed to be risk factors associated with pulmonary dysfunction in COVID-19 survivors 3 months post-hospital discharge with the development of PCS. PCS has systemic manifestations that resolve with time with no further complications. However, the final outcomes of PCS are chiefly unknown. Persistence of inflammatory reactions, autoimmune mimicry, and reactivation of pathogens together with host microbiome alterations may contribute to the development of PCS. The deregulated release of inflammatory mediators in MCAS produces extraordinary symptoms in patients with PCS. The development of MCAS during the course of SARS-CoV-2 infection is correlated to COVID-19 severity and the development of PCS. Therefore, MCAS is treated by antihistamines, inhibition of synthesis of mediators, inhibition of mediator release, and inhibition of degranulation of mast cells.

Post-COVID (PCS) syndrome may progress in association with the development of mast cell activation syndrome (MCAS).

High D-dimer levels and blood urea nitrogen were observed to be risk factors associated with pulmonary dysfunction in COVID-19 survivors 3 months post-hospital discharge with the development of PCS.

Persistence of inflammatory reactions, autoimmune mimicry, and reactivation of pathogens together with host microbiome alterations may contribute to the development of PCS.

MCAS is treated by antihistamines, inhibition of synthesis of mediators, inhibition of mediator release, and inhibition of degranulation of mast cells.

Long COVID: a narrative review of the clinical aftermaths of COVID-19 with a focus on the putative pathophysiology and aspects of physical activity

The pandemic coronavirus disease 2019 (COVID-19) can cause multi-systemic symptoms that can persist beyond the acute symptomatic phase. The post-acute sequelae of COVID-19 (PASC), also referred to as long COVID, describe the persistence of symptoms and/or long-term complications beyond 4 weeks from the onset of the acute symptoms and are estimated to affect at least 20% of the individuals infected with SARS-CoV-2 regardless of their acute disease severity. The multi-faceted clinical picture of long COVID encompasses a plethora of undulating clinical manifestations impacting various body systems such as fatigue, headache, attention disorder, hair loss and exercise intolerance. The physiological response to exercise testing is characterized by a reduced aerobic capacity, cardiocirculatory limitations, dysfunctional breathing patterns and an impaired ability to extract and use oxygen. Still, to this day, the causative pathophysiological mechanisms of long COVID remain to be elucidated, with long-term organ damage, immune system dysregulation and endotheliopathy being among the hypotheses discussed. Likewise, there is still a paucity of treatment options and evidence-based strategies for the management of the symptoms. In sum, this review explores different aspects of long COVID and maps the literature on what is known about its clinical manifestations, potential pathophysiological mechanisms, and treatment options.

Targeting COVID-19 vaccine hesitancy among nurses in Shanghai: A latent profile analysis

Objectives

This study aims to clarify the profiles of the psychological antecedents of vaccine hesitancy among Shanghai nurses with a person-centered approach.

Methods

A population-based cross-sectional online survey was conducted on Shanghai nurses from July to August 2021 (N = 1,928). In the online survey, participants were asked to report their sociodemographic, the 5C vaccine hesitancy components, their knowledge level of COVID-19 vaccine and vaccination, and the COVID-19 vaccination uptake intention and attention to vaccine news. Latent profile analysis was used to reveal distinct profiles of vaccine hesitancy.

Results

The results revealed four profiles, including "believers" (68.9%; high confidence and collective responsibility), "free riders" (12.7%; similar characteristics to believers, except for a low collective responsibility), "middlemen" (14.6%; middle in all 5C constructs), and "contradictors" (3.7%; high in all 5C constructs). Compared to believers, middlemen were younger, more likely to be female, childless, less educated, held lower professional titles, had fewer years of nursing service, sometimes or never complied with recommended vaccinations, had satisfactory or poor self-assessed health status, had no work experience during the COVID-19 epidemic, and possessed greater levels of knowledge. Free riders were more likely to work in community health centers and have a lower degree than believers. Contradictors were more likely to work in community health centers, had junior college degrees or lower, and had no work experience during the COVID-19 epidemic than believers. From the highest to the lowest on vaccination intention and attention to vaccine news were believers, then free riders, contradictors, and finally middlemen.

Conclusion

This study could aid in the development of personalized vaccination strategies based on nurses' vaccine hesitancy profiles and predictors. In addition to vaccine believers, we identified other three profiles based on their 5C psychological antecedents, emphasizing the significance of establishing tailored vaccination campaigns. Further research into the prevalence of profile structure in other groups of healthcare workers is required.

Coronavirus Disease 2019 Severity and Risk of Subsequent Cardiovascular Events

BACKGROUND

Little is known about the relationship between coronavirus disease 2019 (COVID-19) severity and subsequent risk of experiencing a cardiovascular event (CVE) after COVID-19 recovery. We evaluated this relationship in a large cohort of United States adults.

METHODS

Using a claims database, we performed a retrospective cohort study of adults diagnosed with COVID-19 between 1 April 2020 and 31 May 2021. We evaluated the association between COVID-19 severity and risk of CVE >30 days after COVID-19 diagnosis using inverse probability of treatment-weighted competing risks regression. Severity was based on level of care required for COVID-19 treatment: intensive care unit (ICU) admission, non-ICU hospitalization, or outpatient care only.

RESULTS

A total of 1 357 518 COVID-19 patients were included (2% ICU, 3% non-ICU hospitalization, and 95% outpatient only). Compared to outpatients, there was an increased risk of any CVE for patients requiring ICU admission (adjusted hazard ratio [aHR], 1.80 [95% confidence interval {CI}, 1.71-1.89]) or non-ICU hospitalization (aHR, 1.28 [95% CI, 1.24-1.33]). Risk of subsequent hospitalization for CVE was even higher (aHRs, 3.47 [95% CI, 3.20-3.76] for ICU and 1.96 [95% CI, 1.85-2.09] for non-ICU hospitalized vs outpatient only).

CONCLUSIONS

COVID-19 patients hospitalized or requiring critical care had a significantly higher risk of experiencing and being hospitalized for post-COVID-19 CVE than patients with milder COVID-19 who were managed solely in the outpatient setting, even after adjusting for differences between these groups. These findings underscore the continued importance of preventing severe acute respiratory syndrome coronavirus 2 infection from progressing to severe illness to reduce potential long-term cardiovascular complications.

An Insight Into Pathophysiology, Epidemiology, and Management of Cardiovascular Complications of SARS-CoV-2 Infection, Post-acute COVID Syndrome, and COVID Vaccine

Coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic health emergency in March 2020. Elderly patients and those with pre-existing medical conditions including cardiovascular disease are at increased risk of developing severe disease. Not only is the viral infection with SARS-CoV-2 associated with higher mortality in patients with underlying cardiovascular disease, but development of cardiovascular complications is also common in patients with COVID-19. Even after recovery from the acute illness, post-acute COVID syndrome with cardiopulmonary manifestations can occur in some patients. Additionally, there are rare but increasingly recognized adverse events, including cardiovascular side effects, reported with currently available COVID-19 vaccines. In this review, we discuss the most common cardiovascular complications of SARS-CoV-2 and COVID-19 vaccines, cardiopulmonary manifestations of post-acute COVID syndrome and the current evidence-based guidance on the management of such complications.

Cardiac postacute sequelae symptoms of SARS-CoV-2 in community-dwelling adults: cross-sectional study

Objective

To examine risk factors for cardiac-related postacute sequelae of SARS-CoV-2 infection (PASC) in community-dwelling adults after acute COVID-19 infection.

Methods

We performed a cross-sectional analysis among adults who tested positive for COVID-19. Outcomes were self-reported cardiac-related PASC. We conducted stepwise multivariable logistic regression to assess association between the risk factors (existing cardiovascular disease (CVD), pre-existing conditions, days since positive test, COVID-19 hospitalisation, age, sex, education, income) and cardiac-related PASC.

Results

In a sample of 442 persons, mean (SD) age was 45.4 (16.2) years, 71% were women, 13% were black, 46% had pre-existing conditions, 23% had cardiovascular (CV) risk factors and 4% had CVD. Prevalence of cardiac PASC was 43% and newly diagnosed cardiac conditions were 27%. The odds for cardiac-related PASC were higher among persons with underlying pre-existing conditions (adjusted OR (aOR): 2.00, 95% CI: 1.28 to 3.10) and among those who were hospitalised (aOR: 3.03, 95% CI: 1.58 to 5.83).

Conclusions

More than a third of persons with COVID-19 reported cardiac-related PASC symptoms. Underlying CVD, pre-existing diseases, age and COVID-19 hospitalisation are possible risk factors for cardiac-related PASC symptoms. COVID-19 may exacerbate CV risk factors and increase risk of complications.

Introducing the Monitoring Equipment Mask Environment

Filter face masks are Respiratory Protective Equipment designed to protect the wearer from various hazards, suit various health situations, and match the specific requirements of the wearer. Current traditional face masks have several limitations. In this paper, we present (ME)2, the Monitoring Equipment Mask Environment: an innovative reusable 3D-printed eco-sustainable mask with an interchangeable filter. (ME)2 is equipped with multiple vital sensors on board, connected to a system-on-a-chip micro-controller with computational capabilities, Bluetooth communication, and a rechargeable battery that allows continuous monitoring of the wearer's vital signs. It monitors body temperature, heart rate, and oxygen saturation in a non-invasive, strategically positioned way. (ME)2 is accompanied by a mobile application that provides users' health information. Furthermore, through Edge Computing Artificial Intelligence (Edge AI) modules, it is possible to detect an abnormal and early symptoms linked to possible pathologies, possibly linked to the respiratory or cardiovascular tract, and therefore perform predictive analysis, launch alerts, and recommendations. To validate the feasibility of embedded in-app Edge AI modules, we tested a machine learning model able to distinguish COVID-19 versus seasonal influenza using only vital signs. By generating new synthetic data, we confirm the highly reliable performances of such a model, with an accuracy of 94.80%.

Pathogenic role of cytokines in COVID-19, its association with contributing co-morbidities and possible therapeutic regimens

The Covid-19, a threatening pandemic, was originated from China in December 2019 and spread quickly to all over the world. The pathogenesis of coronavirus is linked with the disproportionate response of the immune system. This involves the systemic inflammatory reaction which is characterized by marked pro-inflammatory cytokine release commonly known as cytokine release storm (CRS). The pro inflammatory cytokines are involved in cascade of pulmonary inflammation, hyper coagulation and thrombosis which may be lethal for the individual. That’s why, it is very important to have understanding of pro inflammatory cytokines and their pathological role in SARS-CoV-2. The pathogenesis of Covid is not the same in every individual, it can vary due to the presence of pre-existing comorbidities like suffering from already an inflammatory disease such as rheumatoid arthritis (RA), inflammatory bowel disease (IBD), chronic obstructive pulmonary disease (COPD), an immune-compromised patients suffering from Diabetes Mellitus (DM) and Tuberculosis (TB) are more vulnerable morbidity and complications following COVID-19. This review is particularly related to COVID-19 patients having comorbidity of other inflammatory diseases. We have discussed the brief pathogenesis of COVID-19 and cytokines release storm with reference to other co-morbidities including RA, IBD, COPD, DM and TB. The available therapeutic regimens for COVID-19 including cytokine inhibitors, anti-viral, anti-biotic, bronchodilators, JAK- inhibitors, immunomodulators and anti-fibrotic agents have also been discussed briefly. Moreover, newly emerging medicines in the clinical trials have also been discussed which are found to be effective in treating Covid-19.

Relevance of the post-COVID syndrome within rehabilitation (PoCoRe): study protocol of a multi-centre study with different specialisations

BACKGROUND

In Patients suffering from post-COVID syndrome, in addition to physical limitations, cognitive limitations, fatigue, dyspnea as well as depression and anxiety disorders may also be present. Up to now (as of May 2022), approx. 514 million people worldwide have been infected with SARS-CoV-2, in Germany this affects approx. 25 million. In Germany, 2.5 million people could potentially be affected by post-COVID syndrome. Post-COVID is thus a highly relevant public health issue. So far, there is no specific causal therapy for the post-COVID syndrome, but with multimodal symptom-oriented rehabilitation, the course can be favourably influenced. However, there is no study yet that focuses on patients in different rehabilitation indications and compares the focal symptomatology and coping strategies as well as the patients' benefit per indication.

METHODS/DESIGN

As first objective, pulmonal, cardiac, neurological, cognitive or/and psychological functional impairments in rehabilitation patients after COVID-19 disease will be described. The second objective is the differentiated review of the specific rehabilitation measures, in the short term and in the longer term for the purpose of future prognoses and optimisation of therapeutic interventions. This prospective, non-randomised, controlled longitudinal study, plus multi-group comparisons will take place in seven rehabilitation clinics of different specialisations: cardiological rehab, pneumological rehab, neurological rehab, psychosomatic rehab. Within 12 months, 1000 cases across all participating centres will be included. Somatic and psychological testing will be conducted at three measurement points: Admission (t0), discharge (t1), 6-montas Catamnesis (t2). The patients receive the usual care according to the respective rehabilitation priorities, adapted to the special challenges of post-COVID symptoms. Patients of the post-COVID outpatient clinic without rehabilitation will be used as a control group.

DISCUSSION

This study will precisely assess the extent to which subclinical neurological or/and psychological impairments are present in post-COVID-19 rehabilitation and the results will help, developing, providing and evaluating appropriate treatment concepts. This may also have relevant implications for the improvement of physical ability and quality of life in post-COVID-19 patients and increase the probability of return to work. Trial registration Z-2022-1749-8, registered 03. February 2022, https://studienanmeldung.zks-regensburg.de.

Neuromuskuläre Manifestationen beim Long-COVID-Syndrom

Unter dem Long-COVID(„coronavirus disease“)-Syndrom werden Beschwerden zusammengefasst, die nach einer akuten SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion auftreten, über einen Zeitraum von mehreren Wochen anhalten und nicht durch eine andere Diagnose erklärt werden können. Long-COVID wird als Multiorganmanifestation aufgefasst. In diesem Übersichtsartikel wird die Datenlage hinsichtlich neuromuskulärer Manifestationen des Long-COVID-Syndroms summiert und anhand von Kriterien wie Effektstärke, Plausibilität, Kohärenz und experimentelle Evidenz bewertet. Bisher sind vor allem Myalgien und eine autonome Dysfunktion (u. a. das posturale Tachykardiesyndrom) als neuromuskuläre Symptome von Long-COVID beschrieben worden. Die bisherige Evidenz ist allerdings gering: Neben einer sehr heterogenen Methodik und unterschiedlichen Definitionen in den klinischen Long-COVID-Studien fehlen schlüssige experimentelle Daten, die die beschriebenen Symptome als spezifische Langzeitfolge von COVID-19 belegen.

Cardiovascular symptom phenotypes of post-acute sequelae of SARS-CoV-2

Background

Acute COVID-19 infection has been shown to have significant effects on the cardiovascular system. Post-acute sequelae of SARS-CoV-2 (PASC) are being identified in patients; however, the cardiovascular effects are yet to be well-defined. The Post-COVID Cardiology Clinic at Washington University evaluates and treats patients with ongoing cardiovascular PASC.

Objectives

This investigation aims to describe the phenotypes of cardiovascular symptoms of PASC in patients presenting to the Post-COVID Cardiology Clinic, including their demographics, symptoms, and the clinical phenotypes observed.

Methods

This was a retrospective analysis of symptoms, clinical findings, and test results from the first 100 consecutive adult patients who presented to the Post-COVID Cardiology Clinic at Washington University in St. Louis, between September 2020 to May 2021 with cardiovascular symptoms following COVID-19 infection.

Results

The population (n = 100) had a mean age of 46.3 years and was 81% female. Most patients had mild acute illness, with only 23% of patients requiring hospitalization during acute COVID-19 infection. The most commonly reported PASC symptoms were chest pain (66%), palpitations (59%), and dyspnea on exertion (56%). Of those presenting with these symptoms, 74/98 patients (75.5%) were found to have a significant blood pressure elevation, considerable sinus tachycardia burden, reduced global longitudinal strain, increased indexed left-ventricular end-diastolic volume (LVEDVi) by echocardiogram, and/or cMRI findings consistent with possible active or healing myocarditis.

Conclusions

Our findings highlight clinical phenotypes of the cardiovascular manifestations of PASC. Further studies are needed to evaluate the pathophysiology, treatment options and long-term outcomes for these patients.

Postural orthostatic tachycardia syndrome and post-acute COVID-19

While the acute illness of COVID-19 was the initial focus of concern, there are increasing reports of patients with chronic symptoms, known as long-COVID. Dysautonomia may be a possible post-acute neurological complication explaining the persistent symptoms observed in long COVID. Postural tachycardia syndrome (POTS), a form of dysautonomia characterized by sustained tachycardia and orthostatic intolerance, has been increasingly reported in patients after SARS-CoV-2 infection. In this context, this review aimed to report and discuss the available literature pertaining to post COVID-19 POTS.

Long COVID: Association of Functional Autoantibodies against G-Protein-Coupled Receptors with an Impaired Retinal Microcirculation

Long COVID (LC) describes the clinical phenotype of symptoms after infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Diagnostic and therapeutic options are limited, as the pathomechanism of LC is elusive. As the number of acute SARS-CoV-2 infections was and is large, LC will be a challenge for the healthcare system. Previous studies revealed an impaired blood flow, the formation of microclots, and autoimmune mechanisms as potential factors in this complex interplay. Since functionally active autoantibodies against G-protein-coupled receptors (GPCR-AAbs) were observed in patients after SARS-CoV-2 infection, this study aimed to correlate the appearance of GPCR-AAbs with capillary microcirculation. The seropositivity of GPCR-AAbs was measured by an established cardiomyocyte bioassay in 42 patients with LC and 6 controls. Retinal microcirculation was measured by OCT–angiography and quantified as macula and peripapillary vessel density (VD) by the Erlangen-Angio Tool. A statistical analysis yielded impaired VD in patients with LC compared to the controls, which was accentuated in female persons. A significant decrease in macula and peripapillary VD for AAbs targeting adrenergic β2-receptor, MAS-receptor angiotensin-II-type-1 receptor, and adrenergic α1-receptor were observed. The present study might suggest that a seropositivity of GPCR-AAbs can be linked to an impaired retinal capillary microcirculation, potentially mirroring the systemic microcirculation with consecutive clinical symptoms.

Inappropriate Sinus Tachycardia: Etiology, Pathophysiology, and Management: JACC Review Topic of the Week

Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Although the most common symptom is palpitations, it can be accompanied by a myriad of symptoms, including anxiety, dizziness, presyncope, and syncope. The pathogenesis of IST is not well understood and considered multifactorial, with autonomic dysfunction being the central abnormality. IST is a diagnosis of exclusion. Management presents a clinical challenge. The overall efficacy of lifestyle modifications and medical therapy may be limited. Recent advances in catheter and surgical sinus node sparing ablation techniques have led to improvement in outcomes. In addition, increased focus has led to development of multimodality team-based interventions to improve outcomes in this group of patients. In this review, we discuss the mechanistic basis of IST, review current approaches to diagnosis, and outline contemporary therapeutic approaches.

Comparative efficacy of ivabradine and beta-blockers in the treatment of tachycardia in patients after COVID-19

Aim. To assess the changes of heart rate (HR), exercise tolerance and quality of life in patients after coronavirus disease 2019 (COVID-19) during treatment with ivabradine monotherapy or in combination with beta-blockers (BB) compared with BB monotherapy.

Material and methods. This randomized comparative study included 90 patients discharged from a university hospital after an acute COVID-19. The main group (n=60) received, in addition to standard therapy, ivabradine monotherapy or in combination with BB, while the control one (n=30) — standard therapy in combination with BB. The follow-up period lasted 24 weeks. Statistical processing was performed using the STATISTICA 8.0 program. The level of statistical significance was p<0,05.

Results. There was a significant decrease in heart rate, an increase in physical activity, as well as an improvement in the quality of life in both groups. In the ivabradine group, significantly lower heart rates (71,2±4,1 vs 73,9±5,1 bpm (p=0,015)), significantly higher increase in physical activity (80 (60; 135) vs 65 m (40; 100) (p=0,017)) and quality of life (35 (27; 45) vs 30 (26; 36) points (p=0,03)) was revealed.

Conclusion. It has been shown that ivabradine and beta-blockers can be used in post-COVID-19 tachycardia. Ivabradine monotherapy or in combination with beta-blockers causes a more pronounced decrease in heart rate compared to beta-blocker monotherapy, accompanied by a significant improvement in exercise tolerance and quality of life in this category of patients.

Smoking increases the risk of post-acute COVID-19 syndrome: Results from a French community-based survey

INTRODUCTION

METHODS

RESULTS

CONCLUSIONS

Intermittent left bundle branch block with septal flash and postural orthostatic tachycardia syndrome in a young woman with long COVID-19

The emerging entity, long COVID -19 is characterised by long-lasting dyspnoea, fatigue, cognitive dysfunction and other symptoms. Cardiac involvement manifested as conduction abnormalities, left ventricle mechanical dyssynchrony, dyspnoea, palpitation and postural orthostatic tachycardia syndrome (POTS) are common in long COVID-19. The direct viral damage to the myocardium or immune-mediated inflammation are postulated mechanisms. A woman in her forties presented with a 2-month history of chest pain, functional dyspnoea, palpitation and an episode of syncope after having been home-isolated for mild COVID infection. During clinical workup, a clustering of ECG and echocardiographic abnormalities including left bundle branch block, septal flash, and presystolic wave on spectral Doppler echocardiography, and POTS were detected. The echocardiographic findings together with POTS and persistent dyspnoea indicated the presence of a long COVID-19 state. The prevalence and clinical significance of these finding, as well as the impact on long-term prognosis, should be investigated in future studies.

Cardiovascular Tropism and Sequelae of SARS-CoV-2 Infection

The extrapulmonary manifestation of coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became apparent early in the ongoing pandemic. It is now recognized that cells of the cardiovascular system are targets of SARS-CoV-2 infection and associated disease pathogenesis. While some details are emerging, much remains to be understood pertaining to the mechanistic basis by which SARS-CoV-2 contributes to acute and chronic manifestations of COVID-19. This knowledge has the potential to improve clinical management for the growing populations of patients impacted by COVID-19. Here, we review the epidemiology and pathophysiology of cardiovascular sequelae of COVID-19 and outline proposed disease mechanisms, including direct SARS-CoV-2 infection of major cardiovascular cell types and pathogenic effects of non-infectious viral particles and elicited inflammatory mediators. Finally, we identify the major outstanding questions in cardiovascular COVID-19 research.

Molecular determinants, clinical manifestations and effects of immunization on cardiovascular health during COVID-19 pandemic era - A review

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has enveloped the world into an unprecedented pandemic since 2019. Significant damage to multiple organs, such as the lungs and heart, has been extensively reported. Cardiovascular injury by ACE2 downregulation, hypoxia-induced myocardial injury, and systemic inflammatory responses complicate the disease. This virus causes multisystem inflammatory syndrome in children with similar symptoms to adult SARS-CoV-2-induced myocarditis. While several treatment strategies and immunization programs have been implemented to control the menace of this disease, the risk of long-term cardiovascular damage associated with the disease has not been adequately assessed. In this review, we surveyed and summarized all the available information on the effects of COVID-19 on cardiovascular health as well as comorbidities. We also examined several case reports on post-immunization cardiovascular complications.

Long COVID-19 and Postural Orthostatic Tachycardia Syndrome- Is Dysautonomia to Be Blamed?

While the increased arrhythmic tendency during acute COVID-19 infection is recognised, the long-term cardiac electrophysiological complications are less well known. There are a high number of patients reporting ongoing symptoms post-infection, termed long COVID. A recent hypothesis is that long COVID symptoms could be attributed to dysautonomia, defined as malfunction of the autonomic nervous system (ANS). The most prevalent cardiovascular dysautonomia amongst young people is postural orthostatic tachycardia syndrome (POTS). Numerous reports have described the development of POTS as part of long COVID. Possible underlying mechanisms, although not mutually exclusive or exhaustive, include hypovolaemia, neurotropism, inflammation and autoimmunity. Treatment options for POTS and other long COVID symptoms are currently limited. Future research studies should aim to elucidate the underlying mechanisms of dysautonomia to enable the development of targeted therapies. Furthermore, it is important to educate healthcare professionals to recognise complications and conditions arising from COVID-19, such as POTS, to allow prompt diagnosis and access to early treatment.

Cardio-Oncology in the COVID Era (Co & Co): The Never Ending Story

The pathophysiology of some non-communicable diseases (NCDs) such as hypertension, cardiovascular disease (CVD), diabetes, and cancer includes an alteration of the endothelial function. COVID-19 is a pulmonary and vascular disease with a negative impact on patients whose damaged endothelium is particularly vulnerable. The peculiar SARS-CoV-2-induced “endothelitis” triggers an intriguing immune-thrombosis that affects both the venous and arterial vascular beds. An increased liability for infection and an increased likelihood of a worse outcome have been observed during the pandemic in patients with active cancer and in cancer survivors. “Overlapping commonalities” between COVID-19 and Cardio-Oncology have been described that include shared phenotypes of cardiovascular toxicities such as left ventricular dysfunction, ischemic syndromes, conduction disturbances, myocarditis, pericarditis and right ventricular failure; shared pathophysiologic mechanisms such as inflammation, release of cytokines, the renin-angiotensin-aldosterone-pathway, coagulation abnormalities, microthrombosis and endothelial dysfunction. For these features and for the catalyst role of NCDs (mainly CVD and cancer), we should refer to COVID-19 as a “syndemic.” Another challenging issue is the persistence of the symptoms, the so-called “long COVID” whose pathogenesis is still uncertain: it may be due to persistent multi-organ viral attacks or to an abnormal immune response. An intensive vaccination campaign is the most successful pharmacological weapon against SARS-CoV-2, but the increasing number of variants has reduced the efficacy of the vaccines in controlling SARS-CoV-2 infections. After a year of vaccinations we have also learned more about efficacy and side-effects of COVID-19 vaccines. An important byproduct of the COVID-19 pandemic has been the rapid expansion of telemedicine platforms across different care settings; this new modality of monitoring cancer patients may be useful even in a post pandemic era. In this paper we analyze the problems that the cardio-oncologists are facing in a pandemic scenario modified by the extensive vaccination campaign and add actionable recommendations derived from the ongoing studies and from the syndemic nature of the infection.

Multisystem Involvement in Post-acute Sequelae of COVID-19 (PASC)

OBJECTIVE

To describe cerebrovascular, neuropathic and autonomic features of post-acute sequelae of COVID-19 (PASC).

METHODS

This retrospective study evaluated consecutive patients with chronic fatigue, brain fog and orthostatic intolerance consistent with PASC. Controls included postural tachycardia syndrome patients (POTS) and healthy participants. Analyzed data included surveys and autonomic (Valsalva maneuver, deep breathing, sudomotor and tilt tests), cerebrovascular (cerebral blood flow velocity (CBFv) monitoring in middle cerebral artery), respiratory (capnography monitoring) and neuropathic (skin biopsies for assessment of small fiber neuropathy) testing and inflammatory/autoimmune markers.

RESULTS

Nine PASC patients were evaluated 0.7±0.3 years after a mild COVID-19 infection, treated as home observations. Autonomic, pain, brain fog, fatigue and dyspnea surveys were abnormal in PASC and POTS (n=10), compared to controls (n=15). Tilt table test reproduced the majority of PASC symptoms. Orthostatic CBFv declined in PASC (-20.0±13.4%) and POTS (-20.3±15.1%), compared to controls (-3.0±7.5%,p=0.001) and was independent of end-tidal carbon dioxide in PASC, but caused by hyperventilation in POTS. Reduced orthostatic CBFv in PASC included both subjects without (n=6) and with (n=3) orthostatic tachycardia. Dysautonomia was frequent (100% in both PASC and POTS) but was milder in PASC (p=0.013). PASC and POTS cohorts diverged in frequency of small fiber neuropathy (89% vs. 60%) but not in inflammatory markers (67% vs. 70%). Supine and orthostatic hypocapnia was observed in PASC.

INTERPRETATION

PASC following mild COVID-19 infection is associated with multisystem involvement including: 1) cerebrovascular dysregulation with persistent cerebral arteriolar vasoconstriction; 2) small fiber neuropathy and related dysautonomia; 3) respiratory dysregulation; 4) chronic inflammation. This article is protected by copyright. All rights reserved.

Effusive pericarditis in the pathogenesis of cardiac arrhythmias in COVID-19: a case series

A wide variety of non-pulmonary manifestations of a coronavirus disease 2019 (COVID-19) has enriched clinical performance of cardiac diseases with atypical symptoms. Two COVID-19 cases are presented, where sinus bradycardia and syncope, which are rare in COVID-19, were the leading ones after the infection. The patients had no prior cardiovascular diseases, while the examination did not detected neurological pathology and myocarditis. Echocardiography showed relatively small pericardial effusion, which is supposed to be a cause of the symptoms as the diagnosis to exclude. A local buildup of inflammatory fluid around the sinus node and extensive ganglion plexuses around the atria can possibly affect the automatism and chronotropic compensation in addition to the myocardial inflammation. As part of the treatment against the hydropericardium syndrome, the symptoms disappeared, without reoccurring within subsequent 6-month follow-up. The third clinical case regards the pandemic outbreak, when we could not even suspect that the systemic inflammation would persist for many months after COVID-19 and radiofrequency ablation can lead to sudden cardiac death.

Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know?

Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and “brain fog”. Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.