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Long COVID and the Autonomic Nervous System: The Journey from Dysautonomia to Therapeutic Neuro-Modulation through the Retrospective Analysis of 152 Patients. NEUROSCI 2022. [DOI: 10.3390/neurosci3020021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction. The severity and prevalence of Post-Acute COVID-19 Sequela (PACS) or long-COVID syndrome (long COVID) should not be a surprise. Long-COVID symptoms may be explained by oxidative stress and parasympathetic and sympathetic (P&S) dysfunction. This is a retrospective, hypothesis generating, outcomes study. Methods. From two suburban practices in northeastern United States, 152 long COVID patients were exposed to the following practices: (1) first, they were P&S tested (P&S Monitor 4.0; Physio PS, Inc., Atlanta, GA, USA) prior to being infected with COVID-19 due to other causes of autonomic dysfunction; (2) received a pre-COVID-19 follow-up P&S test after autonomic therapy; (3) then, they were infected with COVID-19; (4) P&S tested within three months of surviving the COVID-19 infection with long-COVID symptoms; and, finally, (5) post-COVID-19, follow-up P&S tested, again, after autonomic therapy. All the patients completed autonomic questionnaires with each test. This cohort included 88 females (57.8%), with an average age of 47.0 years (ranging from 14 to 79 years), and an average BMI of 26.9 #/in2. Results. More pre-COVID-19 patients presented with sympathetic withdrawal than parasympathetic excess. Post-COVID-19, these patients presented with this ratio reversed and, on average, 49.9% more autonomic symptoms than they did pre-COVID-19. Discussion. Both parasympathetic excess and sympathetic withdrawal are separate and treatable autonomic dysfunctions and autonomic treatment significantly reduces the prevalence of autonomic symptoms. Conclusion. SARS-CoV-2, via its oxidative stress, can lead to P&S dysfunction, which, in turn, affects the control and coordination of all systems throughout the whole body and may explain all of the symptoms of long-COVID syndrome. Autonomic therapy leads to positive outcomes and patient quality of life may be restored.
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O’ Mahony L, Buwalda T, Blair M, Forde B, Lunjani N, Ambikan A, Neogi U, Barrett P, Geary E, O'Connor N, Dineen J, Clarke G, Kelleher E, Horgan M, Jackson A, Sadlier C. Impact of Long COVID on health and quality of life. HRB Open Res 2022; 5:31. [PMID: 36101871 PMCID: PMC9440374 DOI: 10.12688/hrbopenres.13516.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/17/2022] Open
Abstract
Background: The aim of this study was to measure the impact of post-acute sequelae of COVID-19 (PASC) on quality of life, mental health, ability to work and return to baseline health in an Irish cohort. Methods: We invited individuals with symptoms of COVID-19 lasting more than 14 days to participate in an anonymous online questionnaire. Basic demographic data and self-reported symptoms were recorded. Internationally validated instruments including the patient health questionnaire somatic, anxiety and depressive symptom scales (PHQ-SADS), the Patient Health Questionnaire-15 (PHQ-15) and Chadler fatigue scale (CFQ) were used. Results: We analysed responses from 988 participants with self-reported confirmed (diagnostic/antibody positive; 81%) or suspected (diagnostic/antibody negative or untested; 9%) COVID-19. The majority of respondents were female (88%), white (98%), with a median age of 43.0 (range 15 – 88 years old) and a median BMI of 26.0 (range 16 – 60). At the time of completing this survey, 89% of respondents reported that they have not returned to their pre-COVID-19 level of health. The median number of symptoms reported was 8 (range 0 to 33 symptoms), with a median duration of 12 months (range 1 to 20 months) since time of acute infection. A high proportion of PASC patients reported that they have a moderate or severe limitation in their ability to carry out their usual activities, 38% report their ability to work is severely limited and 33% report a moderate, or higher, level of anxiety or depression. Conclusion: The results of this survey of an Irish cohort with PASC are in line with reports from other settings, and we confirm that patients with PASC reported prolonged, multi-system symptoms which can significantly impact quality of life, affect ability to work and cause significant disability. Dedicated multidisciplinary, cross specialty supports are required to improve outcomes of this patient group.
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Affiliation(s)
- Liam O’ Mahony
- Department of Medicine, University College Cork, Cork, Ireland
- School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
| | | | - Matthew Blair
- Department of Infectious Disease, Cork University Hospital, Cork, Ireland
| | - Brian Forde
- School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
| | - Nonhlanhla Lunjani
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
| | - Anoop Ambikan
- The Systems Virology Lab,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, ANA Futura, Campus Flemingsberg, Stockholm, Sweden
| | - Ujjwal Neogi
- The Systems Virology Lab,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, ANA Futura, Campus Flemingsberg, Stockholm, Sweden
| | - Peter Barrett
- Department of Public Health, HSE South, St Finbarr’s Hospital, Cork, Ireland
| | - Eoin Geary
- Liaison Psychiatry Service, Cork University Hospital, Cork, Ireland
- Department of Psychiatry and Neurobehavioural Science, University College Cork, National University of Ireland, Cork, Ireland
| | - Nuala O'Connor
- Irish College of General Practitioners, ICGP, Dublin, Ireland
| | - Jennifer Dineen
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Gerard Clarke
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Eric Kelleher
- Liaison Psychiatry Service, Cork University Hospital, Cork, Ireland
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Mary Horgan
- Department of Medicine, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
- Department of Infectious Disease, Cork University Hospital, Cork, Ireland
| | - Arthur Jackson
- Department of Medicine, University College Cork, Cork, Ireland
- Department of Infectious Disease, Cork University Hospital, Cork, Ireland
| | - Corinna Sadlier
- Department of Medicine, University College Cork, Cork, Ireland
- Department of Infectious Disease, Cork University Hospital, Cork, Ireland
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Borlotti A, Thomaides-Brears H, Georgiopoulos G, Banerjee R, Robson MD, Fusco DN, Masci PG. The Additive Value of Cardiovascular Magnetic Resonance in Convalescent COVID-19 Patients. Front Cardiovasc Med 2022; 9:854750. [PMID: 35463767 PMCID: PMC9021393 DOI: 10.3389/fcvm.2022.854750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/28/2022] [Indexed: 01/08/2023] Open
Abstract
In COVID-19 the development of severe viral pneumonia that is coupled with systemic inflammatory response triggers multi-organ failure and is of major concern. Cardiac involvement occurs in nearly 60% of patients with pre-existing cardiovascular conditions and heralds worse clinical outcome. Diagnoses carried out in the acute phase of COVID-19 rely upon increased levels of circulating cardiac injury biomarkers and transthoracic echocardiography. These diagnostics, however, were unable to pinpoint the mechanisms of cardiac injury in COVID-19 patients. Identifying the main features of cardiac injury remains an urgent yet unmet need in cardiology, given the potential clinical consequences. Cardiovascular magnetic resonance (CMR) provides an unparalleled opportunity to gain a deeper insight into myocardial injury given its unique ability to interrogate the properties of myocardial tissue. This endeavor is particularly important in convalescent COVID-19 patients as many continue to experience chest pain, palpitations, dyspnea and exertional fatigue, six or more months after the acute illness. This review will provide a critical appraisal of research on cardiovascular damage in convalescent adult COVID-19 patients with an emphasis on the use of CMR and its value to our understanding of organ damage.
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Affiliation(s)
- Alessandra Borlotti
- Perspectum Ltd., Oxford, United Kingdom
- *Correspondence: Alessandra Borlotti,
| | | | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Dahlene N. Fusco
- Tulane University School of Medicine, New Orleans, LA, United States
| | - Pier-Giorgio Masci
- Perspectum Ltd., Oxford, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
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Zwick RH. [Outpatient pulmonary rehabilitation]. DER PNEUMOLOGE 2022; 19:150-157. [PMID: 35370531 PMCID: PMC8953964 DOI: 10.1007/s10405-022-00442-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Outpatient pulmonary rehabilitation (PR) plays a central role in the integrative care of patients with pulmonary diseases. MATERIAL AND METHODS The article gives an overview of the recent evidence on outpatient PR in various diseases, in various settings including the cost-effectiveness. This is based on a selective literature search in the PubMed and Medline databanks, current expert opinions and clinical experiences. RESULTS Early rehabilitation after exacerbation in COPD patients leads to a reduction of rehospitalizations (hazard ratio 0.83) and to a reduction of mortality (hazard ratio 0.63) over a period of 12 months. Telerehabilitation is a promising future perspective in specific settings. Recent publications on bronchiectasis, interstitial lung diseases and pulmonary hypertension could confirm the safety and feasibility of outpatient PR and the cost-effectiveness could be demonstrated. Also, the evidence for inpatient as well as outpatient PR settings for patients with post-COVID and long COVID is growing. CONCLUSION There is growing equivalence with respect to the evidence on PR, independent of whether it is carried out in an outpatient or inpatient setting.
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Affiliation(s)
- Ralf Harun Zwick
- Therme Wien Med, Ludwig Boltzmann Institut für Rehabilitationsforschung, Kurbadstr. 14, 1100 Wien, Österreich
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55
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Affiliation(s)
- Satish R Raj
- Department of Cardiac Sciences (Raj, Sheldon), Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Autonomic Dysfunction Center (Raj), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.; Department of Cardiology (Fedorowski), Karolinska University Hospital; Department of Medicine (Fedorowski), Karolinska Institute, Stockholm, Sweden
| | - Artur Fedorowski
- Department of Cardiac Sciences (Raj, Sheldon), Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Autonomic Dysfunction Center (Raj), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.; Department of Cardiology (Fedorowski), Karolinska University Hospital; Department of Medicine (Fedorowski), Karolinska Institute, Stockholm, Sweden
| | - Robert S Sheldon
- Department of Cardiac Sciences (Raj, Sheldon), Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Autonomic Dysfunction Center (Raj), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.; Department of Cardiology (Fedorowski), Karolinska University Hospital; Department of Medicine (Fedorowski), Karolinska Institute, Stockholm, Sweden
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Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS. CURRENT PEDIATRICS REPORTS 2022; 10:31-44. [PMID: 35287333 PMCID: PMC8906524 DOI: 10.1007/s40124-022-00261-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 12/13/2022]
Abstract
Purpose of Review To discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management. Recent Findings The recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance). Summary We do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-022-00261-4.
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Jost K, Rodriguez B, Söll N, Hoepner R, Z'Graggen WJ. Tolerability of COVID-19 mRNA vaccines in patients with postural tachycardia syndrome: a cross-sectional study. F1000Res 2022; 11:215. [PMID: 37822957 PMCID: PMC10562791 DOI: 10.12688/f1000research.109373.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 10/13/2023] Open
Abstract
Background: Postural tachycardia syndrome (POTS) is a form of autonomic dysregulation. There is increasing evidence that the etiology may be immune-mediated in a subgroup of patients. Patients with POTS often experience an exacerbation of their symptoms associated with (viral) infections and often fear the same symptom aggravation after vaccination. In this report we describe the tolerability of messenger ribonucleic acid (mRNA) vaccines against coronavirus disease 19 (COVID-19) and the consequences of a COVID-19 infection on POTS symptoms in our cohort of patients with neuropathic POTS. Methods: We conducted a standardized, checklist-based interview with 23 patients and recorded the acute side effects of mRNA vaccination, acute symptoms of COVID-19 infection as well as the effects of vaccination and COVID-19 infection on POTS symptoms. Results: Of all included patients, 20 patients received two mRNA vaccines without having had a previous COVID-19 infection, and five patients in total had suffered a COVID-19 infection. Of these, three had COVID-19 without and two after being vaccinated. No increased frequency of side effects after both doses of mRNA vaccines was observed. Six patients reported a mild and short-term aggravation of their POTS symptoms beyond the duration of acute vaccine side effects. All five patients who suffered a COVID-19 infection subsequently reported a pronounced and persistent exacerbation of POTS symptoms. Conclusions: Our observations suggest that mRNA vaccines are not associated with a higher frequency of acute side effects in patients with POTS. Symptom exacerbation as a consequence of mRNA vaccination seems to be less frequent and of shorter duration compared to patients who suffered a COVID-19 infection.
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Affiliation(s)
- Karin Jost
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Belén Rodriguez
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
| | - Werner J. Z'Graggen
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Bern, 3010, Switzerland
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Abstract
Coronavirus disease 2019 (COVID-19) has encompassed the globe since it was first observed just under 2 years ago. Although the disease is predominantly a respiratory illness, there have been observed complications throughout the various organ systems. Namely, cardiovascular complications, and, more specifically, arrhythmic complications have been described throughout the pandemic in patients with COVID-19. Management of atrial arrhythmias, ventricular arrhythmias, and bradyarrhythmias in patients with COVID-19 infection has been largely guided by our prior experience in the management of these arrhythmias in similar patient populations without infection. However, this review aims to highlight the specific considerations as they pertain to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the various arrhythmic manifestations observed with this disease.
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Affiliation(s)
| | | | - Elaine Y. Wan
- Address reprint requests and correspondence: Dr Elaine Wan, MD, FACC, FAHA, FHRS, Esther Aboodi Associate Professor of Medicine, 622 W 168th St, PH 3-Center, New York, NY 10032.
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Long-COVID Syndrome and the Cardiovascular System: A Review of Neurocardiologic Effects on Multiple Systems. Curr Cardiol Rep 2022; 24:1711-1726. [PMID: 36178611 PMCID: PMC9524329 DOI: 10.1007/s11886-022-01786-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Long-COVID syndrome is a multi-organ disorder that persists beyond 12 weeks post-acute SARS-CoV-2 infection (COVID-19). Here, we provide a definition for this syndrome and discuss neuro-cardiology involvement due to the effects of (1) angiotensin-converting enzyme 2 receptors (the entry points for the virus), (2) inflammation, and (3) oxidative stress (the resultant effects of the virus). RECENT FINDINGS These effects may produce a spectrum of cardio-neuro effects (e.g., myocardial injury, primary arrhythmia, and cardiac symptoms due to autonomic dysfunction) which may affect all systems of the body. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. Together with a full noninvasive cardiac workup, a full assessment of the autonomic nervous system, specifying parasympathetic and sympathetic (P&S) activity, both at rest and in response to challenges, is recommended. Cardiac symptoms must be treated directly. Cardiac treatment is often facilitated by treating the P&S dysfunction. Cardiac symptoms of dyspnea, chest pain, and palpitations, for example, need to be assessed objectively to differentiate cardiac from neural (autonomic) etiology. Long-term myocardial injury commonly involves P&S dysfunction. P&S assessment usually connects symptoms of Long-COVID to the documented autonomic dysfunction(s).
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Ternushchak TM, Tovt-Korshynska MI, Varvarynets AV. AMBULATORY BLOOD PRESSURE VARIABILITY IN YOUNG ADULTS WITH LONG-COVID SYNDROME. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2481-2485. [PMID: 36472284 DOI: 10.36740/wlek202210131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim: To perform an overall assessment of BP and BP variability using ambulatory measurements in young adults with long COVID syndrome. PATIENTS AND METHODS Materials and methods: We enrolled young patients with diagnosed long-COVID syndrome (n = 58, mean age 23.07 ± 1.54 years), compared with an age-matched healthy subjects who had not suffered from COVID-19 (n = 57, mean age 22.9 ± 1.83 years). Patients with long-COVID syndrome had recovered from mild/moderate illness and none had required hospitalization. Ambulatory 24 hours blood pressure (AMBP) parameters (mean BP, daytime BP, nighttime BP, pulse pressure, nocturnal systolic BP dipping, dipper status) were measured in all participants. The variability of systolic BP (SBP) and diastolic BP (DBP) values was assessed by the following common metrics, including the average real variability (ARV), the coefficient of variation (CV), the standard deviation (SD), and the weighed SD of SBP and DBP. RESULTS Results: The average values of 24-hour ambulatory blood pressure, mean BP, daytime and nighttime systolic BP, diastolic BP and pulse pressure were found to be significantly different among patients with long COVID syndrome and control group. Group analyses showed that this difference was in SBP mean values (127.1 ± 6.65 mmHg and 115.93 ± 6.24 mmHg respectively) and DBP mean values (73.31 ± 5.30 mmHg and 68.79 ± 5.5 mmHg respectively) mainly at night. PP values at daytime were almost similar among groups, but PP values at nighttime were higher in patients with long-COVID syndrome (53.8 (52.44- 55.14) mmHg and 47.14 (46.45 - 47.88) mmHg respectively). Nocturnal SBP dipping was better in control group than in patients with long-COVID syndrome ( 5.3 ± 5.68 and 3.1 ± 3.79 mmHg respectively). Only 13 (22.4%) patients with long-COVID syndrome had normal dip-per status while more than half - 38 (66.7%) in healthy subjects. The values of ARV of SBP and DBP over 24-hour, awake, and asleep time frames were found to be greater in patients with long COVID syndrome than healthy controls (p < 0.05). CONCLUSION Conclusions: Patients with long- COVID syndrome have higher BP mean values of 24-hour ABPM particularly at nightime, significant blood pressure BP variability, which increases the risk of cardiovascular events in future. Nevertheless, the further prospective investigations is warranted to investigate the potential mechanisms and causality associations.
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Novak P, Mukerji SS, Alabsi HS, Systrom D, Marciano SP, Felsenstein D, Mullally WJ, Pilgrim DM. Multisystem Involvement in Post-acute Sequelae of COVID-19 (PASC). Ann Neurol 2021; 91:367-379. [PMID: 34952975 PMCID: PMC9011495 DOI: 10.1002/ana.26286] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Shibani S Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Haitham S Alabsi
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David Systrom
- Department of Medicine, Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Sadie P Marciano
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Donna Felsenstein
- Department of Infectious Disease and Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - William J Mullally
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David M Pilgrim
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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