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Park JH, Park S, Kim NH, Lee Y, Chang Y, Song TJ. Postural Orthostatic Tachycardia Syndrome Associated with COVID-19: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1325. [PMID: 39202605 PMCID: PMC11356245 DOI: 10.3390/medicina60081325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a complex condition marked by an atypical autonomic response to standing, leading to orthostatic intolerance and significant tachycardia without accompanying hypotension. In recent studies, a considerable number of individuals recovering from COVID-19 have been reported to experience POTS within 6 to 8 months post-infection. Key symptoms of POTS include fatigue, difficulty with orthostatic tolerance, tachycardia, and cognitive challenges. The underlying causes of POTS following COVID-19 remain unknown, with various theories proposed such as renin-angiotensin-aldosterone system (RAAS) dysregulation, hyperadrenergic reaction, and direct viral infection. Healthcare professionals should be vigilant for POTS in patients who have recovered from COVID-19 and are experiencing signs of autonomic dysfunction and use diagnostic procedures such as the tilt-up table test for confirmation. COVID-19-related POTS should be approached with a holistic strategy. Although many patients show improvement with initial non-drug treatments, for subjects who do not respond and exhibit more severe symptoms, medication-based therapies may be necessary. The current understanding of COVID-19-related POTS is limited, underscoring the need for more research to increase knowledge and enhance treatment approaches.
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Affiliation(s)
- Jung-Hyun Park
- Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea; (J.-H.P.); (S.P.); (N.-H.K.); (Y.L.)
| | - Somin Park
- Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea; (J.-H.P.); (S.P.); (N.-H.K.); (Y.L.)
| | - Na-Hye Kim
- Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea; (J.-H.P.); (S.P.); (N.-H.K.); (Y.L.)
| | - Yoonjin Lee
- Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea; (J.-H.P.); (S.P.); (N.-H.K.); (Y.L.)
| | - Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul 07985, Republic of Korea;
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea
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2
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Kwon HR, Bae DW, An JY. Acquired idiopathic generalized anhidrosis (AIGA) associated with SARS-CoV-2 infection. Acta Neurol Belg 2024:10.1007/s13760-024-02622-w. [PMID: 39133455 DOI: 10.1007/s13760-024-02622-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/08/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Hye Ryung Kwon
- Department of Neurology, College of Medicine, St. Vincent's hospital, The Catholic University of Korea, Seoul, 442-723, Republic of Korea
| | - Dae Woong Bae
- Department of Neurology, College of Medicine, St. Vincent's hospital, The Catholic University of Korea, Seoul, 442-723, Republic of Korea
| | - Jae Young An
- Department of Neurology, College of Medicine, St. Vincent's hospital, The Catholic University of Korea, Seoul, 442-723, Republic of Korea.
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3
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Mustonen T, Kanerva M, Luukkonen R, Lantto H, Uusitalo A, Piirilä P. Cardiopulmonary exercise testing in long covid shows the presence of dysautonomia or chronotropic incompetence independent of subjective exercise intolerance and fatigue. BMC Cardiovasc Disord 2024; 24:413. [PMID: 39117999 PMCID: PMC11308233 DOI: 10.1186/s12872-024-04081-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND After COVID-19 infection, 10-20% of patients suffer from varying symptoms lasting more than 12 weeks (Long COVID, LC). Exercise intolerance and fatigue are common in LC. The aim was to measure the maximal exercise capacity of the LC patients with these symptoms and to analyze whether this capacity was related to heart rate (HR) responses at rest and during exercise and recovery, to find out possible sympathetic overactivity, dysautonomia or chronotropic incompetence. METHODS Cardiopulmonary exercise test was conducted on 101 LC patients, who were admitted to exercise testing. The majority of them (86%) had been treated at home during their acute COVID-19 infection. Peak oxygen uptake (VO2peak), maximal power during the last 4 min of exercise (Wlast4), HRs, and other exercise test variables were compared between those with or without subjective exercise intolerance, fatigue, or both. RESULTS The measurements were performed in mean 12.7 months (SD 5.75) after COVID-19 infection in patients with exercise intolerance (group EI, 19 patients), fatigue (group F, 31 patients), their combination (group EI + F, 37 patients), or neither (group N, 14 patients). Exercise capacity was, in the mean, normal in all symptom groups and did not significantly differ among them. HRs were higher in group EI + F than in group N at maximum exercise (169/min vs. 158/min, p = 0.034) and 10 min after exercise (104/min vs. 87/min, p = 0.028). Independent of symptoms, 12 patients filled the criteria of dysautonomia associated with slightly decreased Wlast4 (73% vs. 91% of sex, age, height, and weight-based reference values p = 0.017) and 13 filled the criteria of chronotropic incompetence with the lowest Wlast4 (63% vs. 93%, p < 0.001), VO2peak (70% vs. 94%, p < 0.001), the lowest increase of systolic blood pressure (50 mmHg vs. 67 mmHg, p = 0.001), and the greatest prevalence of slight ECG-findings (p = 0.017) compared to patients without these features. The highest prevalence of chronotropic incompetence was seen in the group N (p = 0.022). CONCLUSIONS This study on LC patients with different symptoms showed that cardiopulmonary exercise capacity was in mean normal, with increased sympathetic activity in most patients. However, we identified subgroups with dysautonomia or chronotropic incompetence with a lowered exercise capacity as measured by Wlast4 or VO2peak. Subjective exercise intolerance and fatigue poorly foresaw the level of exercise capacity. The results could be used to plan the rehabilitation from LC and for selection of the patients suitable for it.
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Affiliation(s)
- Timo Mustonen
- Department of Clinical Physiology, Peijas Hospital, HUS Medical Diagnostic Center, Helsinki University Hospital and Helsinki University, Stenbäckinkatu 11 C, PL 281, Helsinki, 00029, Finland.
| | - Mari Kanerva
- Department of Internal Medicine and Rehabilitation, Helsinki University and Helsinki University Hospital, Helsinki, Finland
- Department of Infection Control, Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | | | - Hanna Lantto
- Department of Clinical Physiology, Park Hospital, HUS Medical Diagnostic Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Arja Uusitalo
- Division of Clinical Physiology and Nuclear Medicine, HUS Medical Diagnostic Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Päivi Piirilä
- Department of Clinical Physiology, Park Hospital, HUS Medical Diagnostic Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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4
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Broussard CA, Azola A, Rowe PC. Post-Acute Sequelae of SARS-CoV-2 Infection and Its Impact on Adolescents and Young Adults. Pediatr Clin North Am 2024; 71:613-630. [PMID: 39003005 DOI: 10.1016/j.pcl.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2024]
Abstract
This review discusses the varying definitions for post-acute sequelae of SARS CoV-2 infection (PASC) in adolescents and young adults (AYAs), symptom profiles of AYAs with PASC, and assessment and management strategies when AYAs present with symptoms concerning for PASC. Additionally, it reviews the impact that PASC can have on AYAs and includes strategies for providers to support AYAs with PASC. Finally, it concludes with a discussion around equity in the care of AYAs with possible PASC.
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Affiliation(s)
- Camille A Broussard
- Department of Pediatrics, Division of Adolescent & Young Adult Medicine, Johns Hopkins School of Medicine, 200 North Wolfe Street Room 2067, Baltimore, MD 21287, USA.
| | - Alba Azola
- Department of Pediatrics, Division of Adolescent & Young Adult Medicine, Johns Hopkins School of Medicine, 200 North Wolfe Street Room 2069, Baltimore, MD 21287, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, 200 North Wolfe Street Room 2069, Baltimore, MD 21287, USA
| | - Peter C Rowe
- Department of Pediatrics, Division of Adolescent & Young Adult Medicine, Johns Hopkins School of Medicine, 200 North Wolfe Street Room 2077, Baltimore, MD 21287, USA
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5
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Davenport TE, Blitshteyn S, Clague-Baker N, Davies-Payne D, Treisman GJ, Tyson SF. Long COVID Is Not a Functional Neurologic Disorder. J Pers Med 2024; 14:799. [PMID: 39201991 PMCID: PMC11355889 DOI: 10.3390/jpm14080799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 09/03/2024] Open
Abstract
Long COVID is a common sequela of SARS-CoV-2 infection. Data from numerous scientific studies indicate that long COVID involves a complex interaction between pathophysiological processes. Long COVID may involve the development of new diagnosable health conditions and exacerbation of pre-existing health conditions. However, despite this rapidly accumulating body of evidence regarding the pathobiology of long COVID, psychogenic and functional interpretations of the illness presentation continue to be endorsed by some healthcare professionals, creating confusion and inappropriate diagnostic and therapeutic pathways for people living with long COVID. The purpose of this perspective is to present a clinical and scientific rationale for why long COVID should not be considered as a functional neurologic disorder. It will begin by discussing the parallel historical development of pathobiological and psychosomatic/sociogenic diagnostic constructs arising from a common root in neurasthenia, which has resulted in the collective understandings of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and functional neurologic disorder (FND), respectively. We will also review the case definition criteria for FND and the distinguishing clinical and neuroimaging findings in FND vs. long COVID. We conclude that considering long COVID as FND is inappropriate based on differentiating pathophysiologic mechanisms and distinguishing clinical findings.
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Affiliation(s)
- Todd E. Davenport
- Department of Physical Therapy, University of the Pacific, Stockton, CA 95211, USA
- Workwell Foundation, Santa Rosa, CA 95403, USA
| | - Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY 14203, USA
- Dysautonomia Clinic, Williamsville, NY 14221, USA
| | - Nicola Clague-Baker
- School of Allied Health Professions and Nursing, Institute of Population Health, University of Liverpool, Liverpool L69 7ZX, UK
| | - David Davies-Payne
- Department of Radiology, Starship Children’s Hospital, Auckland 1023, New Zealand
| | - Glenn J. Treisman
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA;
| | - Sarah F. Tyson
- School of Health Sciences, University of Manchester, Manchester M14 4PX, UK;
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6
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Joyce JD, Moore GA, Goswami P, Harrell TL, Taylor TM, Hawks SA, Green JC, Jia M, Irwin MD, Leslie E, Duggal NK, Thompson CK, Bertke AS. SARS-CoV-2 Rapidly Infects Peripheral Sensory and Autonomic Neurons, Contributing to Central Nervous System Neuroinvasion before Viremia. Int J Mol Sci 2024; 25:8245. [PMID: 39125815 PMCID: PMC11311394 DOI: 10.3390/ijms25158245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/17/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Neurological symptoms associated with COVID-19, acute and long term, suggest SARS-CoV-2 affects both the peripheral and central nervous systems (PNS/CNS). Although studies have shown olfactory and hematogenous invasion into the CNS, coinciding with neuroinflammation, little attention has been paid to susceptibility of the PNS to infection or to its contribution to CNS invasion. Here we show that sensory and autonomic neurons in the PNS are susceptible to productive infection with SARS-CoV-2 and outline physiological and molecular mechanisms mediating neuroinvasion. Our infection of K18-hACE2 mice, wild-type mice, and golden Syrian hamsters, as well as primary peripheral sensory and autonomic neuronal cultures, show viral RNA, proteins, and infectious virus in PNS neurons, satellite glial cells, and functionally connected CNS tissues. Additionally, we demonstrate, in vitro, that neuropilin-1 facilitates SARS-CoV-2 neuronal entry. SARS-CoV-2 rapidly invades the PNS prior to viremia, establishes a productive infection in peripheral neurons, and results in sensory symptoms often reported by COVID-19 patients.
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Affiliation(s)
- Jonathan D. Joyce
- Translational Biology, Medicine, and Health, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA; (J.D.J.)
- Center for Emerging Zoonotic and Arthropod-borne Pathogens, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Greyson A. Moore
- Biomedical and Veterinary Science, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Poorna Goswami
- Translational Biology, Medicine, and Health, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA; (J.D.J.)
| | - Telvin L. Harrell
- Biomedical and Veterinary Science, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Tina M. Taylor
- Population Health Sciences, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Seth A. Hawks
- Biomedical Sciences and Pathobiology, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Jillian C. Green
- Biomedical and Veterinary Science, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Mo Jia
- Population Health Sciences, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Matthew D. Irwin
- Biomedical and Veterinary Science, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Emma Leslie
- Translational Biology, Medicine, and Health, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA; (J.D.J.)
| | - Nisha K. Duggal
- Center for Emerging Zoonotic and Arthropod-borne Pathogens, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
- Biomedical Sciences and Pathobiology, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Christopher K. Thompson
- School of Neuroscience, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
| | - Andrea S. Bertke
- Center for Emerging Zoonotic and Arthropod-borne Pathogens, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
- Population Health Sciences, Virginia Maryland College of Veterinary Medicine, Virginia Polytechnic Institute & State University, Blacksburg, VA 24060, USA
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Sunami Y, Sugaya K, Takahashi K. G protein-coupled receptors related to autoimmunity in postural orthostatic tachycardia syndrome. Immunol Med 2024:1-8. [PMID: 38900132 DOI: 10.1080/25785826.2024.2370079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is characterized by exaggerated orthostatic tachycardia in the absence of orthostatic hypotension. The pathophysiology of POTS may involve hypovolemia, autonomic neuropathy, a hyperadrenergic state, and cardiovascular deconditioning, any of which can co-occur in the same patient. Furthermore, there is growing evidence of the role of autoimmunity in a subset of POTS cases. In recent years, investigators have described an increased rate of autoimmune comorbidities as evidenced by the finding of several types of neural receptor autoantibody and non-specific autoimmune marker in patients with POTS. In particular, the association of the disease with several types of anti-G protein-coupled receptor (GPCR) antibodies and POTS has frequently been noted. A previous study reported that autoantibodies to muscarinic AChRs may play an important role in POTS with persistent, gastrointestinal symptoms. To date, POTS is recognized as one of the sequelae of coronavirus disease 2019 (COVID-19) and its frequency and pathogenesis are still largely unknown. Multiple autoantibody types occur in COVID-related, autonomic disorders, suggesting the presence of autoimmune pathology in these disorders. Herein, we review the association of anti-GPCR autoantibodies with disorders of the autonomic nervous system, in particular POTS, and provide a new perspective for understanding POTS-related autoimmunity.
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Affiliation(s)
- Yoko Sunami
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
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8
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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9
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Peltier AC. Autonomic Dysfunction from Diagnosis to Treatment. Prim Care 2024; 51:359-373. [PMID: 38692780 DOI: 10.1016/j.pop.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Autonomic disorders can present with hypotension, gastrointestinal, genitourinary symptoms, and heat intolerance. Diabetes is the most common causes of autonomic failure, and management should focus on glucose control to prevent developing autonomic symptoms. The most prevalent cause of dysautonomia, or autonomic dysfunction, is Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing characterizes causes for nonspecific symptoms but is not necessary in patients with classic presentations. Treatment for autonomic dysfunction and failure focus on discontinuing offending medications, behavioral modification, and pharmacologic therapy to decrease symptom severity. Autonomic failure has no cure; therefore, the focus remains on improving quality of life.
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Affiliation(s)
- Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA; Department of Medicine, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA.
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10
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Rinaldi L, Rigo S, Pani M, Bisoglio A, Khalaf K, Minonzio M, Shiffer D, Romeo MA, Verzeletti P, Ciccarelli M, Bordoni MG, Stranges S, Riboli E, Furlan R, Barbic F. Long-COVID autonomic syndrome in working age and work ability impairment. Sci Rep 2024; 14:11835. [PMID: 38782998 PMCID: PMC11116376 DOI: 10.1038/s41598-024-61455-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Long-COVID19 has been recently associated with long-sick leave and unemployment. The autonomic nervous system functioning may be also affected by SARS-CoV-2, leading to a chronic autonomic syndrome. This latter remains widely unrecognized in clinical practice. In the present study, we assessed the occurrence of Long-COVID19 Autonomic Syndrome in a group of active workers as well as the relationships between their autonomic dysfunction and work ability. This prospective observational study was conducted during the 2nd wave of the pandemic in Italy. Forty-five patients (53.6 ± 8.4 years; 32 M) hospitalized for COVID19, were consecutively enrolled at the time of their hospital discharge (T0) and followed-up for 6 months. Autonomic symptoms and work ability were assessed by COMPASS31 and Work Ability Index questionnaires at T0, one (T1), three and six (T6) months after hospital discharge and compared to those retrospectively collected for a period preceding SARS-CoV-2 infection. Clinical examination and standing test were also performed at T1 and T6. One in three working-age people developed a new autonomic syndrome that was still evident 6 months after the acute infection resolution. This was associated with a significant reduction in the work ability. Recognition of Long-COVID19 Autonomic Syndrome may promote early intervention to facilitate return to work and prevent unemployment.
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Affiliation(s)
- Luca Rinaldi
- Occupational Medicine, IRCCS Salvatore Maugeri, University of Pavia, Pavia, Italy
| | - Stefano Rigo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Margherita Pani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Bisoglio
- Department of Neurosurgery, University Vita e Salute S. Raffaele, Milan, Italy
| | - Kareem Khalaf
- Department of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Maura Minonzio
- IRCCS Humanitas Research Hospital, Internal Medicine, 20089, Rozzano, Italy
| | - Dana Shiffer
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Internal Medicine, 20089, Rozzano, Italy
| | - Maria Angela Romeo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Michele Ciccarelli
- IRCCS Humanitas Research Hospital, Internal Medicine, 20089, Rozzano, Italy
| | | | - Saverio Stranges
- Departments of Epidemiology and Biostatistics, Family Medicine and Medicine, Western University, London, ON, Canada
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Elio Riboli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- School of Public Health, Imperial College London, London, UK
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Internal Medicine, 20089, Rozzano, Italy
| | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- IRCCS Humanitas Research Hospital, Internal Medicine, 20089, Rozzano, Italy.
- Departments of Epidemiology and Biostatistics, Family Medicine and Medicine, Western University, London, ON, Canada.
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11
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Mauro M, Cegolon L, Bestiaco N, Zulian E, Larese Filon F. Heart Rate Variability Modulation Through Slow-Paced Breathing in Health Care Workers with Long COVID: A Case-Control Study. Am J Med 2024:S0002-9343(24)00339-5. [PMID: 38795941 DOI: 10.1016/j.amjmed.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Long COVID is a syndrome persisting 12+ weeks after COVID-19 infection, impacting life and work ability. Autonomic nervous system imbalance has been hypothesized as the cause. This study aims to investigate cardiovascular autonomic function in health care workers (HCWs) with Long COVID and the effectiveness of slow-paced breathing (SPB) on autonomic modulation. METHODS From December 1, 2022 to March 31, 2023, 6655 HCWs of the University Hospitals of Trieste (Northeast Italy) were asked to participate in the study by company-email. Inclusion/exclusion criteria were assessed. Global health status and psychosomatic disorders were evaluated through validated questionnaires. Heart rate variability was assessed by finger-photoplethysmography during spontaneous breathing and SPB, which stimulate vagal response. Long COVID HCWs (G1) were contrasted with Never infected (G2) and Fully recovered COVID-19 workers (G3). RESULTS There were 126 HCWs evaluated. The 58 Long COVID were assessed at a median time because COVID-19 of 419.5 days (interquartile range 269-730) and had significantly more psychosomatic symptoms and lower detectability of spontaneous systolic pressure oscillation at 0.1 Hz (Mayer wave - baroreflex arc) during spontaneous breathing compared with 53 never-infected and 14 fully-recovered HCWs (19%, 42%, and 40%, respectively, P = .027). During SPB, the increase in this parameter was close to controls (91.2%, 100%, and 100%, respectively, P = .09). No other differences in heart rate variability parameters were found among groups. CONCLUSIONS Resting vascular modulation was reduced in Long COVID, while during SPB, baroreflex sensitivity effectively improved. Long-term studies are needed to evaluate whether multiple sessions of breathing exercises can restore basal vascular reactivity and reduce cardiovascular risk in these patients.
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Affiliation(s)
- Marcella Mauro
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy.
| | - Luca Cegolon
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Nicoletta Bestiaco
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Elisa Zulian
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Francesca Larese Filon
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy
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12
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Wang X, Cao X, Liang S, Cai G. Clinical Presentation and Outcomes of Hospitalized Patients with Chronic Kidney Disease and COVID-19 Variant Omicron. Ther Clin Risk Manag 2024; 20:275-288. [PMID: 38779588 PMCID: PMC11110823 DOI: 10.2147/tcrm.s458859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
Purpose To investigate the clinical characteristics of hospitalized patients with chronic kidney disease (CKD) and novel coronavirus (SARS-CoV-2) infection and identify potential risk factors that contribute to mortality. Patients and Methods This is a retrospective study, conducted on patients with CKD who were admitted to the First Medical Center of the People's Liberation Army General Hospital between December 1, 2022, and February 28, 2023. All patients were also infected with SARS-CoV-2. We analyzed the clinical characteristics of patients, and the patients were categorized into a survival group and a death group whose characteristics were compared. Cox regression analysis was used to identify risk factors that affected patient prognosis. Results A total of 406 patients were enrolled in this study, including 298 males (73.4%). The average age was 80.5 (67.0, 88.0) years, and the patients had an average estimated glomerular filtration rate (eGFR) of 50.3 (25.0-79.0) mL/min/1.73m². A total of 158 individuals died during hospitalization, resulting in a mortality rate of 38.9%. Renal function was worse in the death group than in the survival group (P < 0.001). Patients in the death group had more severe COVID-19 disease and higher CKD staging than those in the survival group (all P values < 0.001). Multivariate Cox regression analysis identified several risk factors that affected patient mortality, including being male, a higher resting heart rate (RHR) upon admission, dyspnea, a low lymphocyte count (Lym), a high international standardized ratio (INR), a high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, heart failure, and the need for mechanical ventilation during the disease. Conclusion Hospitalized patients with CKD who were infected with SARS-CoV-2 (38.9%) had a relatively high mortality rate (38.9%). Furthermore, a marked correlation was observed between a reduced eGFR and an increased risk of mortality.
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Affiliation(s)
- Xiaolong Wang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, People’s Republic of China
| | - Xueying Cao
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, People’s Republic of China
| | - Shuang Liang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, People’s Republic of China
| | - Guangyan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, People’s Republic of China
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13
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Delogu AB, Aliberti C, Birritella L, De Rosa G, De Rose C, Morello R, Cambise N, Marino AG, Belmusto A, Tinti L, Di Renzo A, Lanza GA, Buonsenso D. Autonomic cardiac function in children and adolescents with long COVID: a case-controlled study. Eur J Pediatr 2024; 183:2375-2382. [PMID: 38446228 PMCID: PMC11035407 DOI: 10.1007/s00431-024-05503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
Although the mechanisms underlying the pathophysiology of long COVID condition are still debated, there is growing evidence that autonomic dysfunction may play a role in the long-term complications or persisting symptoms observed in a significant proportion of patients after SARS-CoV-2 infection. However, studies focused on autonomic dysfunction have primarily been conducted in adults, while autonomic function has not yet been investigated in pediatric subjects. In this study, for the first time, we assessed whether pediatric patients with long COVID present abnormalities in autonomic cardiac function. Fifty-six long COVID pediatric patients (mean age 10.3 ± 3.8 y) and 27 age-, sex-, and body surface area-matched healthy controls (mean age 10.4 ± 4.5y) underwent a standard 12-lead electrocardiography (ECG) and 24-h ECG Holter monitoring. Autonomic cardiac function was assessed by time-domain and frequency-domain heart rate variability parameters. A comprehensive echocardiographic study was also obtained by two-dimensional echocardiography and tissue Doppler imaging. Data analysis showed that pediatric patients with long COVID had significant changes in HRV variables compared to healthy controls: significantly lower r-MSSD (root mean square of successive RR interval differences, 47.4 ± 16.9 versus 60.4 ± 29.1, p = 0.02), significant higher values VLF (very low frequency, 2077.8 ± 1023.3 versus 494.3 ± 1015.5 ms, p = 0.000), LF (low frequency, 1340.3 ± 635.6 versus 354.6 ± 816.8 ms, p = 0.000), and HF (high frequency, 895.7 ± 575.8 versus 278.9 ± 616.7 ms, p = 0.000). No significant differences were observed between the two groups both in systolic and diastolic parameters by echocardiography. Conclusion: These findings suggest that pediatric patients with long COVID have an imbalance of cardiac autonomic function toward a relative predominance of parasympathetic tone, as already reported in adult patients with long COVID. Further studies are needed to clarify the clinical significance of this autonomic dysfunction and demonstrate its role as a pathophysiological mechanism of long COVID, paving the way for effective therapeutic and preventive strategies. What is Known: • Long Covid in children has been described globally, but studies have mostly focused on collecting the temporal evolution of persisting symptoms. What is New: • Cardiac autonomic imbalance toward a relative predominance of parasympathetic tone is a mechanism underlying Long Covid in children, as also described in adults.
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Affiliation(s)
- A B Delogu
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Aliberti
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Birritella
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - G De Rosa
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - C De Rose
- Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - R Morello
- Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - N Cambise
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A G Marino
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Belmusto
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - L Tinti
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Di Renzo
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G A Lanza
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - D Buonsenso
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome, 00168, Italy.
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14
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Paradiso B, Pauza DH, Limback C, Ottaviani G, Thiene G. From Psychostasis to the Discovery of Cardiac Nerves: The Origins of the Modern Cardiac Neuromodulation Concept. BIOLOGY 2024; 13:266. [PMID: 38666878 PMCID: PMC11047897 DOI: 10.3390/biology13040266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
This review explores the historical development of cardiology knowledge, from ancient Egyptian psychostasis to the modern comprehension of cardiac neuromodulation. In ancient Egyptian religion, psychostasis was the ceremony in which the deceased was judged before gaining access to the afterlife. This ritual was also known as the "weighing of the heart" or "weighing of the soul". The Egyptians believed that the heart, not the brain, was the seat of human wisdom, emotions, and memory. They were the first to recognize the cardiocentric nature of the body, identifying the heart as the center of the circulatory system. Aristotle (fourth century BC) considered the importance of the heart in human physiology in his philosophical analyses. For Galen (third century AD), the heart muscle was the site of the vital spirit, which regulated body temperature. Cardiology knowledge advanced significantly in the 15th century, coinciding with Leonardo da Vinci and Vesalius's pioneering anatomical and physiological studies. It was William Harvey, in the 17th century, who introduced the concept of cardiac circulation. Servet's research and Marcello Malpighi's discovery of arterioles and capillaries provided a more detailed understanding of circulation. Richard Lower emerged as the foremost pioneer of experimental cardiology in the late 17th century. He demonstrated the heart's neural control by tying off the vagus nerve. In 1753, Albrecht von Haller, a professor at Göttingen, was the first to discover the heart's automaticity and the excitation of muscle fibers. Towards the end of the 18th century, Antonio Scarpa challenged the theories of Albrecht von Haller and Johann Bernhard Jacob Behrends, who maintained that the myocardium possessed its own "irritability", on which the heartbeat depended, and was independent of neuronal sensitivity. Instead, Scarpa argued that the heart required innervation to maintain life, refuting Galenic notions. In contemporary times, the study of cardiac innervation has regained prominence, particularly in understanding the post-acute sequelae of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection (PASC), which frequently involves cardiorespiratory symptoms and dysregulation of the intrinsic cardiac innervation. Recently, it has been recognized that post-acute sequelae of acute respiratory infections (ARIs) due to other pathogens can also be a cause of long-term vegetative and somatic symptoms. Understanding cardiac innervation and modulation can help to recognize and treat long COVID and long non-COVID-19 (coronavirus disease 2019) ARIs. This analysis explores the historical foundations of cardiac neuromodulation and its contemporary relevance. By focusing on this concept, we aim to bridge the gap between historical understanding and modern applications. This will illuminate the complex interplay between cardiac function, neural modulation, cardiovascular health, and disease management in the context of long-term cardiorespiratory symptoms and dysregulation of intrinsic cardiac innervations.
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Affiliation(s)
- Beatrice Paradiso
- Lino Rossi Research Center, Department of Biomedical, Surgical and Dental Sciences, Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy;
- Consultant Cyto/Histopathologist (Anatomic Pathologist) Anatomic Pathology Unit, Dolo Hospital Venice, 30031 Dolo, Italy
| | - Dainius H. Pauza
- Faculty of Medicine, Institute of Anatomy, Lithuanian University of Health Sciences Kaunas, 44307 Kaunas, Lithuania;
| | - Clara Limback
- Oxford University Hospitals, NHS Trust, Oxford OX3 7JH, UK;
| | - Giulia Ottaviani
- Lino Rossi Research Center, Department of Biomedical, Surgical and Dental Sciences, Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy;
- Department of Biomedical, Surgical and Dental Sciences, Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
| | - Gaetano Thiene
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy;
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15
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Emerson ND, Lavretsky H, Pittman WQ, Viswanathan N, Siddarth P. An open trial of biofeedback for long COVID. J Psychosom Res 2024; 179:111625. [PMID: 38458016 DOI: 10.1016/j.jpsychores.2024.111625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Biofeedback is a therapeutic treatment model that teaches self-regulation of autonomic functions to alleviate stress-related symptoms. "Long COVID" refers to chronic physical and cognitive sequelae post-SARS-CoV-2 infection. This study examined the efficacy of a six-week intervention, consisting of weekly one-hour sessions combining heart rate variability and temperature biofeedback, for alleviating mood symptoms, somatic symptoms and sleep disturbance of patients diagnosed with long COVID. METHODS Data were collected from 20 adult participants aged 22-63 (Mage = 44.1, SDage = 12.2) with varying long COVID symptoms. Within this single arm design, 16 of the 20 participants completed all six sessions of biofeedback; 14 completed an assessment at the three-month post-treatment time point. RESULTS Participants self-reported significant improvements in somatic, anxiety, and depressive symptoms, sleep quality, quality of life, and number of "bad days" immediately after the intervention and three months later (Cohen's d effect size (ES) = 1.09-0.46). Reduced number of medical doctor visits (ES = 0.85) and prescription drug use over the last month (odds ratio = 0.33), as well as improved emotional wellbeing (ES = 0.97) were observed at the three-month time point only. CONCLUSION Results suggest that this short, readily scalable intervention can be potentially efficacious in alleviating symptoms of long COVID. Despite notable improvements, the major limitation of this study is its lack of control group. While a randomized trial merits study, biofeedback appears to be a brief, effective, non-invasive, and low-cost treatment option for patients with chronic somatic symptoms secondary to SARS-CoV-2 infection. CLINICALTRIALS govID: NCT05120648.
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Affiliation(s)
- Natacha D Emerson
- UCLA Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, United States.
| | - Helen Lavretsky
- UCLA Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, United States
| | - William Q Pittman
- UCLA Department of Medicine, David Geffen School of Medicine, United States
| | - Nisha Viswanathan
- UCLA Department of Medicine, David Geffen School of Medicine, United States
| | - Prabha Siddarth
- UCLA Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, United States
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16
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Cantrell C, Reid C, Walker CS, Stallkamp Tidd SJ, Zhang R, Wilson R. Post-COVID postural orthostatic tachycardia syndrome (POTS): a new phenomenon. Front Neurol 2024; 15:1297964. [PMID: 38585346 PMCID: PMC10998446 DOI: 10.3389/fneur.2024.1297964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
Background The impact of COVID-19 has been far-reaching, and the field of neurology is no exception. Due to the long-hauler effect, a variety of chronic health consequences have occurred for some post-COVID patients. A subset of these long-hauler patients experienced symptoms of autonomic dysfunction and tested positive for postural orthostatic tachycardia syndrome (POTS) via autonomic testing. Methods We conducted a chart review of a convenience sample from patients seen by neurologists at our tertiary care center for suspicion of post-COVID POTS. Patients included in our study had clearly defined POTS based on clinical criteria and positive tilt table test, were 81.25% female, and had an average age of approximately 36. Out of 16 patients, 12 had a confirmed positive COVID test result, with the remaining 4 having strong clinical suspicion for COVID infection. Our analysis examined the most bothersome 3 symptoms affecting each patient per the neurologist's note at their initial visit for post-COVID POTS, clinical presentation, comorbidities, neurological exam findings, autonomic testing results, and COMPASS-31 autonomic questionnaire and PROMIS fatigue survey results. Results Palpitations (68.75%) and fatigue (62.5%) were the most common of the impactful symptoms reported by patients in their initial Cleveland Clinic neurology visit. The most frequent comorbidities in our sample were chronic migraines (37.5%), irritable bowel syndrome (IBS) (18.75%), and Raynaud's (18.75%). Neurological exam findings and autonomic testing results other than tilt table yielded variable findings without clear trends. Survey results showed substantial autonomic symptom burden (COMPASS-31 autonomic questionnaire average score 44.45) and high levels of fatigue (PROMIS fatigue survey average score 64.64) in post-COVID POTS patients. Conclusion Our sample of post-COVID POTS patients are similar to the diagnosed POTS general population including in comorbidities and autonomic testing. Fatigue was identified by patients as a common and debilitating symptom. We hope that our study will be an early step toward further investigation of post-COVID POTS with focus on the trends identified in this chart review.
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Affiliation(s)
| | - Conor Reid
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | - Claudia S. Walker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | | | - Ryan Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robert Wilson
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
- Department of Neuromuscular Medicine, Cleveland Clinic Foundation, Cleveland, OH, United States
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17
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Nakane S, Koike H, Hayashi T, Nakatsuji Y. Autoimmune Autonomic Neuropathy: From Pathogenesis to Diagnosis. Int J Mol Sci 2024; 25:2296. [PMID: 38396973 PMCID: PMC10889307 DOI: 10.3390/ijms25042296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a disease of autonomic failure caused by ganglionic acetylcholine receptor (gAChR) autoantibodies. Although the detection of autoantibodies is important for distinguishing the disease from other neuropathies that present with autonomic dysfunction, other factors are important for accurate diagnosis. Here, we provide a comprehensive review of the clinical features of AAG, highlighting differences in clinical course, clinical presentation, and laboratory findings from other neuropathies presenting with autonomic symptoms. The first step in diagnosing AAG is careful history taking, which should reveal whether the mode of onset is acute or chronic, followed by an examination of the time course of disease progression, including the presentation of autonomic and extra-autonomic symptoms. AAG is a neuropathy that should be differentiated from other neuropathies when the patient presents with autonomic dysfunction. Immune-mediated neuropathies, such as acute autonomic sensory neuropathy, are sometimes difficult to differentiate, and therefore, differences in clinical and laboratory findings should be well understood. Other non-neuropathic conditions, such as postural orthostatic tachycardia syndrome, chronic fatigue syndrome, and long COVID, also present with symptoms similar to those of AAG. Although often challenging, efforts should be made to differentiate among the disease candidates.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Haruki Koike
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
| | - Tomohiro Hayashi
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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18
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Bielecka E, Sielatycki P, Pietraszko P, Zapora-Kurel A, Zbroch E. Elevated Arterial Blood Pressure as a Delayed Complication Following COVID-19-A Narrative Review. Int J Mol Sci 2024; 25:1837. [PMID: 38339115 PMCID: PMC10856065 DOI: 10.3390/ijms25031837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Arterial hypertension is one of the most common and significant cardiovascular risk factors. There are many well-known and identified risk factors for its development. In recent times, there has been growing concern about the potential impact of COVID-19 on the cardiovascular system and its relation to arterial hypertension. Various theories have been developed that suggest a connection between COVID-19 and elevated blood pressure. However, the precise link between SARS-CoV-2 infection and the long-term risk of developing hypertension remains insufficiently explored. Therefore, the primary objective of our study was to investigate the influence of COVID-19 infection on blood pressure elevation and the subsequent risk of developing arterial hypertension over an extended period. To accomplish this, we conducted a thorough search review of relevant papers in the PubMed and SCOPUS databases up to 3 September 2023. Our analysis encompassed a total of 30 eligible articles. Out of the 30 papers we reviewed, 19 of them provided substantial evidence showing a heightened risk of developing arterial hypertension following COVID-19 infection. Eight of the studies showed that blood pressure values increased after the infection, while three of the qualified studies did not report any notable impact of COVID-19 on blood pressure levels. The precise mechanism behind the development of hypertension after COVID-19 remains unclear, but it is suggested that endothelial injury and dysfunction of the renin-angiotensin-aldosterone system may be contributory. Additionally, changes in blood pressure following COVID-19 infection could be linked to lifestyle alterations that often occur alongside the illness. Our findings emphasize the pressing requirement for thorough research into the relationship between COVID-19 and hypertension. These insights are essential for the development of effective prevention and management approaches for individuals who have experienced COVID-19 infection.
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Affiliation(s)
| | | | | | | | - Edyta Zbroch
- Department of Internal Medicine and Hypertension, Medical University of Bialystok, 15-540 Bialystok, Poland; (E.B.); (P.S.); (P.P.); (A.Z.-K.)
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19
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Goerlich E, Chung TH, Hong GH, Metkus TS, Gilotra NA, Post WS, Hays AG. Cardiovascular effects of the post-COVID-19 condition. NATURE CARDIOVASCULAR RESEARCH 2024; 3:118-129. [PMID: 39196189 DOI: 10.1038/s44161-023-00414-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/13/2023] [Indexed: 08/29/2024]
Abstract
Throughout the COVID-19 pandemic, the new clinical entity of the post-COVID-19 condition, defined as a multisystemic condition of persistent symptoms following resolution of an acute severe acute respiratory syndrome coronavirus 2 infection, has emerged as an important area of clinical focus. While this syndrome spans multiple organ systems, cardiovascular complications are often the most prominent features. These include, but are not limited to, myocardial injury, heart failure, arrhythmias, vascular injury/thrombosis and dysautonomia. As the number of individuals with the post-COVID-19 condition continues to climb and overwhelm medical systems, summarizing existing information and knowledge gaps in the complex cardiovascular effects of the post-COVID-19 condition has become critical for patient care. In this Review, we explore the current state of knowledge of the post-COVID-19 condition and identify areas where additional research is warranted. This will provide a framework for better understanding the cardiovascular manifestations of the post-COVID-19 condition with a focus on pathophysiology, diagnosis and management.
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Affiliation(s)
- Erin Goerlich
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation and Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Gloria H Hong
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Allison G Hays
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA.
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20
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Goldstein DS. Post-COVID dysautonomias: what we know and (mainly) what we don't know. Nat Rev Neurol 2024; 20:99-113. [PMID: 38212633 DOI: 10.1038/s41582-023-00917-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/13/2024]
Abstract
Following on from the COVID-19 pandemic is another worldwide public health challenge that is referred to variously as long COVID, post-COVID syndrome or post-acute sequelae of SARS-CoV-2 infection (PASC). PASC comes in many forms and affects all body organs. This heterogeneous presentation suggests involvement of the autonomic nervous system (ANS), which has numerous roles in the maintenance of homeostasis and coordination of responses to various stressors. Thus far, studies of ANS dysregulation in people with PASC have been largely observational and descriptive, based on symptom inventories or objective but indirect measures of cardiovascular function, and have paid little attention to the adrenomedullary, hormonal and enteric nervous components of the ANS. Such investigations do not consider the syndromic nature of autonomic dysfunction. This Review provides an update on the literature relating to ANS abnormalities in people with post-COVID syndrome and presents a theoretical perspective on how the ANS might participate in common features of PASC.
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Affiliation(s)
- David S Goldstein
- Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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21
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McMaster MW, Dey S, Fishkin T, Wang A, Frishman WH, Aronow WS. The Impact of Long COVID-19 on the Cardiovascular System. Cardiol Rev 2024:00045415-990000000-00198. [PMID: 38285646 DOI: 10.1097/crd.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Long coronavirus disease (COVID) is the development or persistence of symptoms after an acute SARS-CoV-2 (COVID-19) infection. Fewer patients are developing acute COVID-19 infections, but patients with long COVID continue to have alarming long-term sequelae. Many cardiac magnetic resonance imaging studies show significant changes in cardiac structure after a COVID-19 infection, suggestive of an increased burden of many cardiovascular diseases, notably myocarditis. The pathophysiology of COVID-19 requires viral binding to angiotensin-converting enzyme 2 protein receptors throughout the body, which are upregulated by inflammation. Consequently, the numerous preexisting conditions that worsen or prolong inflammation enhance this binding and have differing effects on patients based on their unique immune systems. These pathophysiological changes drive long COVID cardiac sequelae such as inappropriate sinus tachycardia, postural orthostatic tachycardia, and other types of orthostatic intolerance. Increased screening for long COVID and low-risk interventions such as exercise regimens could alleviate the suffering endured by patients with long COVID. Many studies such as the Researching COVID to Enhance Recovery Initiative (RECOVER) trials at the National Institutes of Health are exploring potential treatments for long COVID patients.
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Affiliation(s)
- Matthew W McMaster
- From the Departments of Cardiology and Medicine, Westchester Medical Center, Valhalla, NY
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Kounis NG, Gogos C, de Gregorio C, Hung MY, Kounis SN, Tsounis EP, Assimakopoulos SF, Pourmasumi S, Mplani V, Servos G, Dousdampanis P, Plotas P, Michalaki MA, Tsigkas G, Grammatikopoulos G, Velissaris D, Koniar I. "When," "Where," and "How" of SARS-CoV-2 Infection Affects the Human Cardiovascular System: A Narrative Review. Balkan Med J 2024; 41:7-22. [PMID: 38173173 PMCID: PMC10767774 DOI: 10.4274/balkanmedj.galenos.2023.2023-10-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory coronavirus-2 (SARS-CoV-2). Several explanations for the development of cardiovascular complications during and after acute COVID-19 infection have been hypothesized. The COVID-19 pandemic, caused by SARS-CoV-2, has emerged as one of the deadliest pandemics in modern history. The myocardial injury in COVID-19 patients has been associated with coronary spasm, microthrombi formation, plaque rupture, hypoxic injury, or cytokine storm, which have the same pathophysiology as the three clinical variants of Kounis syndrome. The angiotensin-converting enzyme 2 (ACE2), reninaldosterone system (RAAS), and kinin-kallikrein system are the main proposed mechanisms contributing to cardiovascular complications with the COVID-19 infection. ACE receptors can be found in the heart, blood vessels, endothelium, lungs, intestines, testes, neurons, and other human body parts. SARS-CoV-2 directly invades the endothelial cells with ACE2 receptors and constitutes the main pathway through which the virus enters the endothelial cells. This causes angiotensin II accumulation downregulation of the ACE2 receptors, resulting in prothrombotic effects, such as hemostatic imbalance via activation of the coagulation cascade, impaired fibrinolysis, thrombin generation, vasoconstriction, endothelial and platelet activation, and pro-inflammatory cytokine release. The KKS system typically causes vasodilation and regulates tissue repair, inflammation, cell proliferation, and platelet aggregation, but SARS-CoV-2 infection impairs such counterbalancing effects. This cascade results in cardiac arrhythmias, cardiac arrest, cardiomyopathy, cytokine storm, heart failure, ischemic myocardial injuries, microvascular disease, Kounis syndrome, prolonged COVID, myocardial fibrosis, myocarditis, new-onset hypertension, pericarditis, postural orthostatic tachycardia syndrome, pulmonary hypertension, stroke, Takotsubo syndrome, venous thromboembolism, and thrombocytopenia. In this narrative review, we describe and elucidate when, where, and how COVID-19 affects the human cardiovascular system in various parts of the human body that are vulnerable in every patient category, including children and athletes.
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Affiliation(s)
- Nicholas G. Kounis
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Christos Gogos
- Clinic of Cardiology, COVID-19 Unit, Papageorgiou General Hospital, Pavlos Melas, Greece
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, University of Messina Medical School, Messina, Italy
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University Hospital of Patras, Rio, Greece
| | - Stelios F. Assimakopoulos
- Department of Internal Medicine, Division of Infectious Diseases, University of Patras Medical School, Rio, Greece
| | - Soheila Pourmasumi
- Social Determinants of Health Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Virginia Mplani
- Intensive Care Unit, Patras University Hospital, Rio, Greece
| | - George Servos
- Pediatric Cardiology Unit, “P. & A. Kyriakou” Children’s Hospital, Athina, Greece
| | | | - Panagiotis Plotas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Marina A. Michalaki
- Department of Internal Medicine, Division of Endocrinology, University of Patras, School of Health Sciences, Rio, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | | | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras Medical School, Rio, Greece
| | - Ioanna Koniar
- Electrophysiology and Device Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
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23
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Tsuchida T, Ishibashi Y, Inoue Y, Ishizuka K, Katayama K, Hirose M, Nakagama Y, Kido Y, Akashi Y, Otsubo T, Matsuda T, Ohira Y. Treatment of long COVID complicated by postural orthostatic tachycardia syndrome-Case series research. J Gen Fam Med 2024; 25:53-61. [PMID: 38240001 PMCID: PMC10792321 DOI: 10.1002/jgf2.670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/26/2023] [Accepted: 11/29/2023] [Indexed: 01/22/2024] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) sequelae, also known as long COVID, can present with various symptoms. Among these symptoms, autonomic dysregulation, particularly postural orthostatic tachycardia syndrome (POTS), should be evaluated. However, previous studies on the treatment of POTS complicated by COVID-19 are lacking. Therefore, this study aimed to investigate the treatment course of long COVID complicated by POTS. Methods The medical records of patients who complained of fatigue and met the criteria for POTS diagnosis were reviewed. We evaluated the treatment days, methods and changes in fatigue score, changes in heart rate on the Schellong test, and social situation at the first and last visits. Results Thirty-two patients with long COVID complicated by POTS were followed up (16 males; median age: 28 years). The follow-up period was 159 days, and the interval between COVID-19 onset and initial hospital attendance was 97 days. Some patients responded to β-blocker therapy. Many patients had psychiatric symptoms that required psychiatric intervention and selective serotonin reuptake inhibitor prescription. Changes in heart rate, performance status, and employment/education status improved from the first to the last visit. These outcomes were believed to be because of the effects of various treatment interventions and spontaneous improvements. Conclusions Our study suggests that the condition of 94% of patients with POTS complicated by long COVID will improve within 159 days. Therefore, POTS evaluation should be considered when patients with long COVID complain of fatigue, and attention should be paid to psychological symptoms and the social context.
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Affiliation(s)
- Tomoya Tsuchida
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Yuki Ishibashi
- Department of CardiologySt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Yoko Inoue
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Kosuke Ishizuka
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Kohta Katayama
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Masanori Hirose
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Yu Nakagama
- Department of Virology & Parasitology, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
- Research Center for Infectious Disease Sciences, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
| | - Yasutoshi Kido
- Department of Virology & Parasitology, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
- Research Center for Infectious Disease Sciences, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
| | - Yoshihiro Akashi
- Department of CardiologySt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Takehito Otsubo
- Department of Gastroenterological and General SurgerySt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Takahide Matsuda
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Yoshiyuki Ohira
- Department of General Internal MedicineSt. Marianna University School of MedicineKawasakiKanagawaJapan
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24
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Teodorescu DL, Kote A, Reaso JN, Rosenberg C, Liu X, Kwan AC, Cheng S, Chen PS. Postural orthostatic tachycardia syndrome after COVID-19 vaccination. Heart Rhythm 2024; 21:74-81. [PMID: 38176772 PMCID: PMC10767226 DOI: 10.1016/j.hrthm.2023.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/13/2023] [Accepted: 09/11/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND There is an association between coronavirus disease 2019 (COVID-19) mRNA vaccination and the incidence or exacerbation of postural orthostatic tachycardia syndrome (POTS). OBJECTIVE The purpose of this study was to characterize patients reporting new or exacerbated POTS after receiving the mRNA COVID-19 vaccine. METHODS We prospectively collected data from sequential patients in a POTS clinic between July 2021 and June 2022 reporting new or exacerbated POTS symptoms after COVID-19 vaccination. Heart rate variability (HRV) and skin sympathetic nerve activity (SKNA) were compared against those of 24 healthy controls. RESULTS Ten patients (6 women and 4 men; age 41.5 ± 7.9 years) met inclusion criteria. Four patients had standing norepinephrine levels > 600 pg/mL. All patients had conditions that could raise POTS risk, including previous COVID-19 infection (N = 4), hypermobile Ehlers-Danlos syndrome (N = 6), mast cell activation syndrome (N = 6), and autoimmune (N = 7), cardiac (N = 7), neurological (N = 6), or gastrointestinal conditions (N = 4). HRV analysis indicated a lower ambulatory root mean square of successive differences (46.19 ±24 ms; P = .042) vs control (72.49 ± 40.8 ms). SKNA showed a reduced mean amplitude (0.97 ± 0.052 μV; P = .011) vs control (1.2 ± 0.31 μV) and burst amplitude (1.67 ± 0.16 μV; P = .018) vs control (4. 3 ± 4.3 μV). After 417.2 ± 131.4 days of follow-up, all patients reported improvement with the usual POTS care, although 2 with COVID-19 reinfection and 1 with small fiber neuropathy did have relapses of POTS symptoms. CONCLUSION All patients with postvaccination POTS had pre-existing conditions. There was no evidence of myocardial injuries or echocardiographic abnormalities. The decreased HRV suggests a sympathetic dominant state. Although all patients improved with guideline-directed care, there is a risk of relapse.
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Affiliation(s)
- Debbie Lin Teodorescu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anxhela Kote
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jewel N Reaso
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carine Rosenberg
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiao Liu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alan C Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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25
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BROCK MALCOLMV, BOSMANS FRANK. A MULTI-HIT MODEL OF LONG COVID PATHOPHYSIOLOGY: THE INTERACTION BETWEEN IMMUNE TRIGGERS AND NERVOUS SYSTEM SIGNALING. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2024; 134:149-164. [PMID: 39135572 PMCID: PMC11316875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Early in the pandemic, clinicians recognized an overlap between Long COVID symptoms and dysautonomia, suggesting autonomic nervous system (ANS) dysfunction. Our clinical experience at Johns Hopkins with primary dysautonomia suggested heritability of sympathetic dysfunction, manifesting primarily as hyperhidrosis and as other dysautonomia symptoms. Whole exome sequencing revealed mutations in genes regulating electrical signaling in the nervous system, thus providing a genetic basis for the sympathetic overdrive observed. We hypothesize that dysautonomia in Long COVID requires two molecular hits: a genetic vulnerability to prime the ANS and a SARS-CoV-2 infection, as an immune trigger, to further disrupt ANS function resulting in increased sympathetic activity. Indeed, Long COVID patients show signs of chronic inflammation and autoimmunity. We have translated this two-hit concept to the clinic using ion channel inhibitors to target genetic susceptibility and immunomodulators to treat inflammation. This multi-hit hypothesis shows promise for managing Long COVID and merits further study.
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26
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Corrado J, Iftekhar N, Halpin S, Li M, Tarrant R, Grimaldi J, Simms A, O'Connor RJ, Casson A, Sivan M. HEART Rate Variability Biofeedback for LOng COVID Dysautonomia (HEARTLOC): Results of a Feasibility Study. ADVANCES IN REHABILITATION SCIENCE AND PRACTICE 2024; 13:27536351241227261. [PMID: 38298551 PMCID: PMC10826406 DOI: 10.1177/27536351241227261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
Introduction Post-COVID-19 syndrome, or Long Covid (LC) refers to symptoms persisting 12 weeks after the COVID-19 infection. LC comprises a wide range of dysautonomia symptoms, including fatigue, breathlessness, palpitations, dizziness, pain and brain fog. This study tested the feasibility and estimated the efficacy, of a Heart Rate Variability Biofeedback (HRV-B) programme via a standardised slow diaphragmatic breathing technique in individuals with LC. Methods LC patients underwent a 4-week HRV-B intervention for 10 minutes twice daily for 4 weeks using the Polar H10 ECG (Electrocardiogram) chest strap and Elite HRV phone application. Outcome measures C19-YRSm (Yorkshire Rehabilitation Scale modified), Composite Autonomic Symptom Score (COMPASS-31), WHO Disability Assessment Schedule (WHODAS), EQ5D-5L (EuroQol 5 Dimensions) and Root Mean Square of Successive Differences between heartbeats (RMSSD) using a Fitbit device were recorded before and after the intervention. The study was pre-registered at clinicaltrials.gov NCT05228665. Results A total of 13 participants (54% female, 46% male) completed the study with high levels of independent use of technology, data completeness and intervention adherence. There was a statistically significant improvement in C19YRS-m (P = .001), COMPASS-31 (P = .007), RMSSD (P = .047), WHODAS (P = .02) and EQ5D Global Health Score (P = .009). Qualitative feedback suggested participants could use it independently, were satisfied with the intervention and reported beneficial effects from the intervention. Conclusion HRV-B using diaphragmatic breathing is a feasible intervention for LC. The small sample size limits generalisability. HRV-B in LC warrants further exploration in a larger randomised controlled study.
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Affiliation(s)
- Joanna Corrado
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Long COVID Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
- National Demonstration Centre of Rehabilitation Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nafi Iftekhar
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Stephen Halpin
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Long COVID Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
- National Demonstration Centre of Rehabilitation Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mengyao Li
- Department of Electrical and Electronic Engineering, University of Manchester, Manchester, UK
| | - Rachel Tarrant
- Long COVID Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Jennifer Grimaldi
- Long COVID Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Alexander Simms
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rory J O'Connor
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Demonstration Centre of Rehabilitation Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alex Casson
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Department of Electrical and Electronic Engineering, University of Manchester, Manchester, UK
| | - Manoj Sivan
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Long COVID Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
- National Demonstration Centre of Rehabilitation Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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27
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da Silva ALG, Vieira LDP, Dias LS, Prestes CV, Back GD, Goulart CDL, Arena R, Borghi-Silva A, Trimer R. Impact of long COVID on the heart rate variability at rest and during deep breathing maneuver. Sci Rep 2023; 13:22695. [PMID: 38123689 PMCID: PMC10733257 DOI: 10.1038/s41598-023-50276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
While the majority of individuals with coronavirus disease 2019 (COVID-19) recover completely, a significant percentage experience persistent symptom, which has been characterized as Long COVID and may be associated with cardiac and autonomic dysfunction. We evaluated heart rate variability (HRV) at rest and during deep-breathing (M-RSA) in patients with Long COVID. Case-control design involved 21 patients with Long COVID and 20 controls; the HRV was evaluated (POLAR system) at rest in the supine position and during M-RSA and expressed in time domain and non-linear analysis. In the supine position we found a reduction HRV measures in Long COVID' patients compared to controls for: Mean_iRR (p < 0.001), STD_iRR (p < 0.001); STD_HR (p < 0.001); SD1 (p < 0.001); SD2 (p < 0.001); alpha2 (p < 0.001). In the M-RSA we found reduction Mean_iRR (p < 0.001), STD_iRR (p < 0.001), STD_HR (p < 0.001), rMSSD (p < 0.001), RR_tri-index (p < 0.001) in Long COVID' patients except for highest Mean_HR p < 0.001. In conclusion, Long COVID reduced HRV at rest and during deep breathing. These findings may imply impairment of cardiac autonomic control when symptoms of COVID-19 persist following initial recovery.
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Affiliation(s)
- Andréa Lúcia Gonçalves da Silva
- Department of Health Sciences, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil.
- Nucleus of Research in Surveillance, Prevention and Rehabilitation in Cardiorespiratory Diseases, Rio Grande do Sul, Brazil.
| | - Luana Dos Passos Vieira
- Scientific Initiation Scholarship at Laboratory of Cardiorespiratory Rehabilitation, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | - Luiza Scheffer Dias
- Scientific Initiation Scholarship at Laboratory of Cardiorespiratory Rehabilitation, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | - Cecília Vieira Prestes
- Scientific Initiation Scholarship at Laboratory of Cardiorespiratory Rehabilitation, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | - Guilherme Dionir Back
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | - Cassia da Luz Goulart
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | - Renata Trimer
- Department of Health Sciences, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil
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28
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Hira R, Karalasingham K, Baker JR, Raj SR. Autonomic Manifestations of Long-COVID Syndrome. Curr Neurol Neurosci Rep 2023; 23:881-892. [PMID: 37947962 DOI: 10.1007/s11910-023-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Long-COVID is a novel condition emerging from the COVID-19 pandemic. Long-COVID is characterized by symptoms commonly seen in autonomic disorders including fatigue, brain fog, light-headedness, and palpitations. This article will critically evaluate recent findings and studies on Long-COVID and its physiological autonomic manifestations. RECENT FINDINGS Studies have reported on the prevalence of different symptoms and autonomic disorders in Long-COVID cohorts. Autonomic nervous system function, including both the parasympathetic and sympathetic limbs, has been studied using different testing techniques in Long-COVID patients. While numerous mechanisms may contribute to Long-COVID autonomic pathophysiology, it is currently unclear which ones lead to a Long-COVID presentation. To date, studies have not tested treatment options for autonomic disorders in Long-COVID patients. Long-COVID is associated with autonomic abnormalities. There is a high prevalence of clinical autonomic disorders among Long-COVID patients, with limited knowledge of the underlying mechanisms and the effectiveness of treatment options.
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Affiliation(s)
- Rashmin Hira
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kavithra Karalasingham
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jacquie R Baker
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada.
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada.
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29
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Frontera JA, Guekht A, Allegri RF, Ashraf M, Baykan B, Crivelli L, Easton A, Garcia-Azorin D, Helbok R, Joshi J, Koehn J, Koralnik I, Netravathi M, Michael B, Nilo A, Özge A, Padda K, Pellitteri G, Prasad K, Romozzi M, Saylor D, Seed A, Thakur K, Uluduz D, Vogrig A, Welte TM, Westenberg E, Zhuravlev D, Zinchuk M, Winkler AS. Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition. J Neurol Sci 2023; 454:120827. [PMID: 37856998 DOI: 10.1016/j.jns.2023.120827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/14/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
| | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Mariam Ashraf
- Department of Anesthesiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Betül Baykan
- Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, and EMAR Medical Center, Istanbul, Turkey
| | - Lucía Crivelli
- Department of Cognitive Neurology, Fleni, Buenos Aires, Argentina
| | - Ava Easton
- The Encephalitis Society, Malton, UK; Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - David Garcia-Azorin
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria; Department of Neurology, Johannes Kepler University, Linz, Austria
| | - Jatin Joshi
- Department of Anesthesiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Julia Koehn
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Igor Koralnik
- Departmentof Neurology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - M Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Benedict Michael
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Annacarmen Nilo
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Aynur Özge
- Department of Neurology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Karanbir Padda
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Gaia Pellitteri
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Kameshwar Prasad
- Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Marina Romozzi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Adam Seed
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kiran Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Derya Uluduz
- Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, and EMAR Medical Center, Istanbul, Turkey
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine, University of Udine Medical School, Udine, Italy
| | - Tamara M Welte
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany; Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Erica Westenberg
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dmitry Zhuravlev
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Mikhail Zinchuk
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; Blavatnik Institute of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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30
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Azcue N, Del Pino R, Acera M, Fernández-Valle T, Ayo-Mentxakatorre N, Pérez-Concha T, Murueta-Goyena A, Lafuente JV, Prada A, López de Munain A, Ruiz Irastorza G, Martín-Iglesias D, Ribacoba L, Gabilondo I, Gómez-Esteban JC, Tijero-Merino B. Dysautonomia and small fiber neuropathy in post-COVID condition and Chronic Fatigue Syndrome. J Transl Med 2023; 21:814. [PMID: 37968647 PMCID: PMC10648633 DOI: 10.1186/s12967-023-04678-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/28/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and post-COVID condition can present similarities such as fatigue, brain fog, autonomic and neuropathic symptoms. METHODS The study included 87 patients with post-COVID condition, 50 patients with ME/CFS, and 50 healthy controls (HC). The hemodynamic autonomic function was evaluated using the deep breathing technique, Valsalva maneuver, and Tilt test. The presence of autonomic and sensory small fiber neuropathy (SFN) was assessed with the Sudoscan and with heat and cold evoked potentials, respectively. Finally, a complete neuropsychological evaluation was performed. The objective of this study was to analyze and compare the autonomic and neuropathic symptoms in post-COVID condition with ME/CFS, and HC, as well as, analyze the relationship of these symptoms with cognition and fatigue. RESULTS Statistically significant differences were found between groups in heart rate using the Kruskal-Wallis test (H), with ME/CFS group presenting the highest (H = 18.3; p ≤ .001). The Postural Orthostatic Tachycardia Syndrome (POTS), and pathological values in palms on the Sudoscan were found in 31% and 34% of ME/CFS, and 13.8% and 19.5% of post-COVID patients, respectively. Concerning evoked potentials, statistically significant differences were found in response latency to heat stimuli between groups (H = 23.6; p ≤ .01). Latency was highest in ME/CFS, and lowest in HC. Regarding cognition, lower parasympathetic activation was associated with worse cognitive performance. CONCLUSIONS Both syndromes were characterized by inappropriate tachycardia at rest, with a high percentage of patients with POTS. The prolonged latencies for heat stimuli suggested damage to unmyelinated fibers. The higher proportion of patients with pathological results for upper extremities on the Sudoscan suggested a non-length-dependent SFN.
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Affiliation(s)
- N Azcue
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
| | - R Del Pino
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain.
| | - M Acera
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
| | - T Fernández-Valle
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
- Department of Neurology, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
- Department of Neurosciences, University of the Basque Country UPV/EHU, Leioa, Spain
| | - N Ayo-Mentxakatorre
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
| | - T Pérez-Concha
- Department of Neurology, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
- Department of Medicine, School of Medicine, University of Deusto, Bilbao, Spain
| | - A Murueta-Goyena
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
- Department of Neurosciences, University of the Basque Country UPV/EHU, Leioa, Spain
| | - J V Lafuente
- Department of Neurosciences, University of the Basque Country UPV/EHU, Leioa, Spain
| | - A Prada
- Department of Immunology, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain
- Spanish Network for the Research in Multiple Sclerosis, San Sebastian, Spain
| | - A López de Munain
- Department of Neurology, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain
- Department of Neurosciences, Biodonostia Health Research Institute, San Sebastián, Spain
- Department of Neurosciences, University of the Basque Country UPV-EHU, San Sebastián, Spain
- Department of Medicine, School of Medicine, University of Deusto, Bilbao, Spain
- CIBERNED-CIBER, Institute Carlos III, Madrid, Spain
| | - G Ruiz Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Department of Autoimmune Diseases, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
| | - D Martín-Iglesias
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Department of Autoimmune Diseases, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
| | - L Ribacoba
- Department of Internal Medicine, Cruces University Hospital, Barakaldo, Spain
| | - I Gabilondo
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
- Department of Neurology, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
- The Basque Foundation for Science, IKERBASQUE, Bilbao, Spain
| | - J C Gómez-Esteban
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain.
- Department of Neurology, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain.
- Department of Neurosciences, University of the Basque Country UPV/EHU, Leioa, Spain.
- Department of Medicine, School of Medicine, University of Deusto, Bilbao, Spain.
- CIBERNED-CIBER, Institute Carlos III, Madrid, Spain.
| | - B Tijero-Merino
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Plaza de Cruces 12, 48903, Barakaldo (Bizkaia), CP, Spain
- Department of Neurology, Cruces University Hospital-OSAKIDETZA, Barakaldo, Spain
- Department of Medicine, School of Medicine, University of Deusto, Bilbao, Spain
- CIBERNED-CIBER, Institute Carlos III, Madrid, Spain
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Tabacof L, Wood J, Breyman E, Tosto-Mancuso J, Kelly A, Wilkey K, Zhang C, Putrino D, Kontorovich A. Dysautonomia, but Not Cardiac Dysfunction, Is Common in a Cohort of Individuals with Long COVID. J Pers Med 2023; 13:1606. [PMID: 38003921 PMCID: PMC10671897 DOI: 10.3390/jpm13111606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
Despite the prevalence of dysautonomia in people with Long COVID, it is currently unknown whether Long COVID dysautonomia is routinely accompanied by structural or functional cardiac alterations. In this retrospective observational study, the presence of echocardiographic abnormalities was assessed. Left ventricular (LV) chamber sizes were correlated to diagnostic categories and symptoms via standardized patient-reported outcome (PRO) questionnaires. A total of 203 individuals with Long COVID without pre-existing cardiac disease and with available echocardiograms were included (mean age, 45 years; 67% female). Overall, symptoms and PRO scores for fatigue, breathlessness, quality of life, disability, anxiety and depression were not different between those classified with post-COVID dysautonomia (PCD, 22%) and those unclassified (78%). An LV internal diameter at an end-diastole z score < -2 was observed in 33 (16.5%) individuals, and stroke volume (SV) was lower in the PCD vs. unclassified subgroup (51.6 vs. 59.2 mL, 95% C.I. 47.1-56.1 vs. 56.2-62.3). LV end-diastolic volume (mean diff. (95% CI) -13 [-1--26] mL, p = 0.04) and SV (-10 [-1--20] mL, p = 0.03) were smaller in those individuals reporting a reduction in physical activity post-COVID-19 infection, and smaller LVMI was weakly correlated with worse fatigue (r = 0.23, p = 0.02). The majority of individuals with Long COVID report shared symptoms and did not demonstrate cardiac dysfunction on echocardiography.
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Affiliation(s)
- Laura Tabacof
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (J.W.)
| | - Jamie Wood
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (J.W.)
| | - Erica Breyman
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (J.W.)
| | - Jenna Tosto-Mancuso
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (J.W.)
| | - Amanda Kelly
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kaitlyn Wilkey
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Chi Zhang
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.Z.); (A.K.)
| | - David Putrino
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (J.W.)
| | - Amy Kontorovich
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.Z.); (A.K.)
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- The Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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32
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Luchian ML, Higny J, Benoit M, Robaye B, Berners Y, Henry JP, Colle B, Xhaët O, Blommaert D, Droogmans S, Motoc AI, Cosyns B, Gabriel L, Guedes A, Demeure F. Unmasking Pandemic Echoes: An In-Depth Review of Long COVID's Unabated Cardiovascular Consequences beyond 2020. Diagnostics (Basel) 2023; 13:3368. [PMID: 37958264 PMCID: PMC10647305 DOI: 10.3390/diagnostics13213368] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
At the beginning of 2020, coronavirus disease 2019 (COVID-19) emerged as a new pandemic, leading to a worldwide health crisis and overwhelming healthcare systems due to high numbers of hospital admissions, insufficient resources, and a lack of standardized therapeutic protocols. Multiple genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been detected since its first public declaration in 2020, some of them being considered variants of concern (VOCs) corresponding to several pandemic waves. Nevertheless, a growing number of COVID-19 patients are continuously discharged from hospitals, remaining symptomatic even months after their first episode of COVID-19 infection. Long COVID-19 or 'post-acute COVID-19 syndrome' emerged as the new pandemic, being characterized by a high variability of clinical manifestations ranging from cardiorespiratory and neurological symptoms such as chest pain, exertional dyspnoea or cognitive disturbance to psychological disturbances, e.g., depression, anxiety or sleep disturbance with a crucial impact on patients' quality of life. Moreover, Long COVID is viewed as a new cardiovascular risk factor capable of modifying the trajectory of current and future cardiovascular diseases, altering the patients' prognosis. Therefore, in this review we address the current definitions of Long COVID and its pathophysiology, with a focus on cardiovascular manifestations. Furthermore, we aim to review the mechanisms of acute and chronic cardiac injury and the variety of cardiovascular sequelae observed in recovered COVID-19 patients, in addition to the potential role of Long COVID clinics in the medical management of this new condition. We will further address the role of future research for a better understanding of the actual impact of Long COVID and future therapeutic directions.
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Affiliation(s)
- Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Yannick Berners
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Jean-Philippe Henry
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benjamin Colle
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Steven Droogmans
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Andreea Iulia Motoc
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
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Bellanti JA, Novak P, Faitelson Y, Bernstein JA, Castells MC. The Long Road of Long COVID: Specific Considerations for the Allergist/Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3335-3345. [PMID: 37774781 DOI: 10.1016/j.jaip.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/08/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023]
Abstract
Long COVID (coronavirus disease 2019) syndrome, also known as post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a new disorder that can develop after an acute infection with the SARS-CoV-2 virus. The condition is characterized by multiorgan system involvement with a wide range of symptoms that can vary in severity from mild to debilitating. Some of the common symptoms associated with long COVID syndrome include cardiovascular issues such as heart palpitations and chest pain; thrombotic events (eg, blood clotting disorders); metabolic problems (eg, type 2 diabetes); dysautonomia; paroxysmal orthostatic tachycardia syndrome; myalgic encephalomyelitis/chronic fatigue syndrome; reactivation of the Epstein-Barr virus; the presence of autoantibodies; chronic spontaneous urticaria (hives); and connective tissue diseases. Whereas long COVID syndrome can affect individuals from various backgrounds, certain populations may be at higher risk such as individuals of Hispanic and Latino heritage, as well as those with low socioeconomic status, although approximately one-third of affected patients have no known risk factors or preexisting conditions. Many survivors of COVID-19 struggle with multiple symptoms, increased disability, reduced function, and poor quality of life. Whereas vaccination has been the most significant intervention able to decrease the severity of acute SARS-Cov2 infection and curtail deaths, limited data are available related to its modulating effect on long COVID necessitating the need for further investigation. Furthermore, several inflammatory pathways have been proposed for the pathogenesis of long COVID that are the targets for ongoing clinical studies evaluating novel pharmacological agents. The purpose of the present report is to review the many factors associated with long COVID with a focus on those aspects that have relevance to the allergist-immunologist.
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Affiliation(s)
- Joseph A Bellanti
- Department of Pediatrics and Department of Microbiology-Immunology, Georgetown University School of Medicine; International Center for Interdisciplinary Studies of Immunology (ICISI), Georgetown University Medical Center, Washington, DC
| | - Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Yoram Faitelson
- Department of Pediatrics Allergy and Immunology, Schneider Children's Hospital, Petach Tikva, Israel
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mariana C Castells
- Drug Hypersensitivity and Desensitization Center and Mastocytosis Center, Brigham and Women's Hospital Division of Allergy and Immunology, Harvard Medical School, Boston, Mass.
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Srivastava P, Nabeel PM, Raj KV, Soneja M, Chandran DS, Joseph J, Wig N, Jaryal AK, Thijssen D, Deepak KK. Baroreflex sensitivity is impaired in survivors of mild COVID-19 at 3-6 months of clinical recovery; association with carotid artery stiffness. Physiol Rep 2023; 11:e15845. [PMID: 37907363 PMCID: PMC10618071 DOI: 10.14814/phy2.15845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/06/2023] [Accepted: 10/05/2023] [Indexed: 11/02/2023] Open
Abstract
The association between the stiffening of barosensitive regions of central arteries and the derangements in baroreflex functions remains unexplored in COVID-19 survivors. Fifty-seven survivors of mild COVID-19 (defined as presence of upper respiratory tract symptoms and/or fever without shortness of breath or hypoxia; SpO2 > 93%), with an age range of 22-66 years (27 females) participated at 3-6 months of recovering from the acute phase of RT-PCR positive COVID-19. Healthy volunteers whose baroreflex sensitivity (BRS) and arterial stiffness data were acquired prior to the onset of the pandemic constituted the control group. BRS was found to be significantly lower in the COVID survivor group for the systolic blood pressure-based sequences (BRSSBP ) [9.78 (7.16-17.74) ms/mmHg vs 16.5 (11.25-23.78) ms/mmHg; p = 0.0253]. The COVID survivor group showed significantly higher carotid β stiffness index [7.16 (5.75-8.18) vs 5.64 (4.34-6.96); (p = 0.0004)], and pulse wave velocity β (PWVβ ) [5.67 (4.96-6.32) m/s vs 5.12 (4.37-5.41) m/s; p = 0.0002]. BRS quantified by both the sequence and spectral methods showed an inverse correlation with PWVβ in the male survivors. Impairment of BRS in the male survivors of mild COVID-19 at 3-6 months of clinical recovery shows association with carotid artery stiffness.
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Affiliation(s)
- Prachi Srivastava
- Department of PhysiologyAll India Institute of Medical SciencesNew DelhiIndia
| | - P. M. Nabeel
- Healthcare Technology Innovation CenterIndian Institute of TechnologyMadrasIndia
| | - Kiran V. Raj
- Department of Electrical EngineeringIndian Institute of TechnologyMadrasIndia
| | - Manish Soneja
- Department of MedicineAll India Institute of Medical SciencesNew DelhiIndia
| | - Dinu S. Chandran
- Department of PhysiologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Jayaraj Joseph
- Healthcare Technology Innovation CenterIndian Institute of TechnologyMadrasIndia
- Department of Electrical EngineeringIndian Institute of TechnologyMadrasIndia
| | - Naveet Wig
- Department of MedicineAll India Institute of Medical SciencesNew DelhiIndia
| | - Ashok Kumar Jaryal
- Department of PhysiologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Dick Thijssen
- Department of PhysiologyRadboud University Medical CenterNijmegenThe Netherlands
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Boegle AK, Narayanaswami P. Infectious Neuropathies. Continuum (Minneap Minn) 2023; 29:1418-1443. [PMID: 37851037 DOI: 10.1212/con.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article discusses the clinical manifestations and management of infectious peripheral neuropathies. LATEST DEVELOPMENTS Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease. ESSENTIAL POINTS Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.
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36
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Abrams RMC, Zhou L, Shin SC. Persistent post-COVID-19 neuromuscular symptoms. Muscle Nerve 2023; 68:350-355. [PMID: 37466117 DOI: 10.1002/mus.27940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
Neuromuscular symptoms may develop or persist after resolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Besides residual sensorimotor symptoms associated with acute neuromuscular complications of coronavirus disease-2019 (COVID-19), such as Guillain-Barré syndrome, critical illness neuromyopathy, and rhabdomyolysis, patients may report persistent autonomic symptoms, sensory symptoms, and muscle symptoms in the absence of these acute complications, including palpitations, orthostatic dizziness and intolerance, paresthesia, myalgia, and fatigue. These symptoms may be associated with long COVID, also known as post-COVID-19 conditions or postacute sequelae of SARS-CoV-2 infection, which may significantly impact quality of life. Managing these symptoms represents a challenge for health-care providers. Recent advances have identified small-fiber neuropathy as a potential etiology that may underlie autonomic dysfunction and paresthesia in some long COVID patients. The pathogenic mechanisms underlying myalgia and fatigue remain elusive and need to be investigated. Herein we review the current state of knowledge regarding the evaluation and management of patients with persistent post-COVID-19 neuromuscular symptoms.
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Affiliation(s)
- Rory M C Abrams
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lan Zhou
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Susan C Shin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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37
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Gunduz GU, Yildiz AM, Yalcinbayir O, Baykara M, Sari ES, Isleker S, Ozturk NAA. Pupillographic Analysis of COVID-19 Patients: Early and Late Results After Recovery. BEYOGLU EYE JOURNAL 2023; 8:149-156. [PMID: 37766761 PMCID: PMC10521134 DOI: 10.14744/bej.2023.30592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 09/29/2023]
Abstract
Objectives We aimed to investigate the short- and long-term static and dynamic pupillary responses of patients recovered from coronavirus disease-19 (COVID-19) using quantitative infrared pupillography. Methods This study included patients who recovered from COVID-19 (Group 1) and age- and gender-matched controls (Group 2). A detailed ophthalmic examination was performed at 1 month and 6 months after the diagnosis of COVID-19. Photopic, mesopic, and scotopic pupil diameters (PDs) were measured using a quantitative infrared pupillography which was integrated into Scheimpflug/Placido photography-based topography system. PDs at 0, 2nd, 4th, and 6th seconds, and average pupil dilation speeds at 2nd, 4th, 6th, and 8th seconds were recorded. Results Eighty-six eyes of 86 patients (Group 1: n=42; Group 2: n=44) were included. While the mean photopic, mesopic, and scotopic PDs were significantly larger in the COVID-19 group than the control group in the 1st month (p=0.035, p=0.017, p=0.018, respectively), no statistically significant difference was found in the 6th month. Besides, average pupil dilation speeds and PDs at the 0, 2nd, 4th, and 6th seconds were not statistically significantly different between the two groups in the 1st month and 6th month. Conclusion PDs were significantly larger in COVID-19 patients in all light intensities in the 1st month after COVID-19. However, pupillary dilation was transient, and no significant difference was found in the 6th month. We suggest that the transient pupillary dilation may be secondary to the autonomic nervous system dysfunction and/or optic nerve and visual pathways alterations following COVID-19.
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Affiliation(s)
- Gamze Ucan Gunduz
- Department of Ophthalmology, Bursa Uludag University, Bursa, Türkiye
| | | | - Ozgur Yalcinbayir
- Department of Ophthalmology, Bursa Uludag University, Bursa, Türkiye
| | - Mehmet Baykara
- Department of Ophthalmology, Bursa Uludag University, Bursa, Türkiye
| | - Esin Sogutlu Sari
- Department of Ophthalmology, Bursa Uludag University, Bursa, Türkiye
| | - Sevde Isleker
- Department of Ophthalmology, Bursa Uludag University, Bursa, Türkiye
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38
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Rigo S, Urechie V, Diedrich A, Okamoto LE, Biaggioni I, Shibao CA. Impaired parasympathetic function in long-COVID postural orthostatic tachycardia syndrome - a case-control study. Bioelectron Med 2023; 9:19. [PMID: 37670400 PMCID: PMC10481607 DOI: 10.1186/s42234-023-00121-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/12/2023] [Indexed: 09/07/2023] Open
Abstract
PURPOSE Eighty percent of patients infected by SARS-CoV-2 report persistence of one symptom beyond the 4-week convalescent period. Those with orthostatic tachycardia and orthostatic symptoms mimicking postural tachycardia syndrome, they are defined as Long-COVID POTS [LCP]. This case-control study investigated potential differences in autonomic cardiovascular regulation between LCP patients and healthy controls. METHODS Thirteen LCP and 16 healthy controls, all female subjects, were studied without medications. Continuous blood pressure and ECG were recorded during orthostatic stress test, respiratory sinus arrhythmia, and Valsalva maneuver. Time domain and power spectral analysis of heart rate [HR] and systolic blood pressure [SBP] variability were computed characterizing cardiac autonomic control and sympathetic peripheral vasoconstriction. RESULTS LCP had higher deltaHR (+ 40 ± 6 vs. + 21 ± 3 bpm, p = 0.004) and deltaSBP (+ 8 ± 4 vs. -1 ± 2 mmHg, p = 0.04) upon standing; 47% had impaired Valsalva maneuver ratio compared with 6.2% in controls (p = 0.01). Spectral analysis revealed that LCP had lower RMSSD (32.1 ± 4.6 vs. 48.9 ± 6.8 ms, p = 0.04) and HFRRI, both in absolute (349 ± 105 vs. 851 ± 253ms2, p = 0.03) and normalized units (32 ± 4 vs. 46 ± 4 n.u., p = 0.02). LFSBP was similar between groups. CONCLUSIONS LCP have reduced cardiovagal modulation, but normal sympathetic cardiac and vasoconstrictive functions. Impaired parasympathetic function may contribute to the pathogenesis of Long-COVID POTS syndrome.
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Affiliation(s)
- Stefano Rigo
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy.
| | - Vasile Urechie
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrè Diedrich
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Luis E Okamoto
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Italo Biaggioni
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cyndya A Shibao
- Department of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
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Wesselingh R. Prevalence, pathogenesis and spectrum of neurological symptoms in COVID-19 and post-COVID-19 syndrome: a narrative review. Med J Aust 2023; 219:230-236. [PMID: 37660309 DOI: 10.5694/mja2.52063] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 09/05/2023]
Abstract
Neurological symptoms are not uncommon during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and reflect a broad spectrum of neurological disorders of which clinicians should be aware. The underlying pathogenesis of neurological disease in coronavirus disease 2019 (COVID-19) may be due to four mechanisms of nervous system dysfunction and injury: i) direct viral neurological invasion; ii) immune dysregulation; iii) endothelial dysfunction and coagulopathy; and iv) severe systemic COVID-19 disease. Neurological manifestations of acute COVID-19 include headache, peripheral neuropathies, seizures, encephalitis, Guillain-Barré syndrome, and cerebrovascular disease. Commonly reported long term neurological sequelae of COVID-19 are cognitive dysfunction and dysautonomia, which despite being associated with severe acute disease are also seen in people with mild disease. Assessment of cognitive dysfunction after COVID-19 is confounded by a high prevalence of comorbid fatigue, anxiety, and mood disorders. However, other markers of neuroaxonal breakdown suggest no significant neuronal injury apart from during severe acute COVID-19. The long term impact of COVID-19 on neurological diseases remains uncertain and requires ongoing vigilance.
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Affiliation(s)
- Robb Wesselingh
- Monash University, Melbourne, VIC
- Alfred Hospital, Melbourne, VIC
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40
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Marques KC, Quaresma JAS, Falcão LFM. Cardiovascular autonomic dysfunction in "Long COVID": pathophysiology, heart rate variability, and inflammatory markers. Front Cardiovasc Med 2023; 10:1256512. [PMID: 37719983 PMCID: PMC10502909 DOI: 10.3389/fcvm.2023.1256512] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
Long COVID is characterized by persistent signs and symptoms that continue or develop for more than 4 weeks after acute COVID-19 infection. Patients with Long COVID experience a cardiovascular autonomic imbalance known as dysautonomia. However, the underlying autonomic pathophysiological mechanisms behind this remain unclear. Current hypotheses include neurotropism, cytokine storms, and inflammatory persistence. Certain immunological factors indicate autoimmune dysfunction, which can be used to identify patients at a higher risk of Long COVID. Heart rate variability can indicate autonomic imbalances in individuals suffering from Long COVID, and measurement is a non-invasive and low-cost method for assessing cardiovascular autonomic modulation. Additionally, biochemical inflammatory markers are used for diagnosing and monitoring Long COVID. These inflammatory markers can be used to improve the understanding of the mechanisms driving the inflammatory response and its effects on the sympathetic and parasympathetic pathways of the autonomic nervous system. Autonomic imbalances in patients with Long COVID may result in lower heart rate variability, impaired vagal activity, and substantial sympathovagal imbalance. New research on this subject must be encouraged to enhance the understanding of the long-term risks that cardiovascular autonomic imbalances can cause in individuals with Long COVID.
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Affiliation(s)
| | - Juarez Antônio Simões Quaresma
- Center for Biological Health Sciences, State University of Pará (UEPA), Belém, Brazil
- School of Medicine, São Paulo University (USP), São Paulo, Brazil
- Tropical Medicine Center, Federal University of Pará (UFPA), Belém, Brazil
| | - Luiz Fábio Magno Falcão
- Center for Biological Health Sciences, State University of Pará (UEPA), Belém, Brazil
- School of Medicine, São Paulo University (USP), São Paulo, Brazil
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41
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Pari B, Babbili A, Kattubadi A, Thakre A, Thotamgari S, Gopinathannair R, Olshansky B, Dominic P. COVID-19 Vaccination and Cardiac Arrhythmias: A Review. Curr Cardiol Rep 2023; 25:925-940. [PMID: 37530946 DOI: 10.1007/s11886-023-01921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW In this review, we aim to delve into the existing literature, seeking to uncover the mechanisms, investigate the electrocardiographic changes, and examine the treatment methods of various cardiac arrhythmias that occur after administration of the COVID-19 vaccine. RECENT FINDINGS A global survey has exposed an incidence of arrhythmia in 18.27% of hospitalized COVID-19 patients. Furthermore, any type of COVID-19 vaccine - be it mRNA, adenovirus vector, whole inactivated, or protein subunit - appears to instigate cardiac arrhythmias. Among the cardiac adverse events reported post-COVID-19 vaccination, myocarditis emerges as the most common and is thought to be a potential cause of bradyarrhythmia. When a patient post-COVID-19 vaccination presents a suspicion of cardiac involvement, clinicians should perform a comprehensive history and physical examination, measure electrolyte levels, conduct ECG, and carry out necessary imaging studies. In our extensive literature search, we uncovered various potential mechanisms that might lead to cardiac conduction abnormalities and autonomic dysfunction in patients who have received the COVID-19 vaccine. These mechanisms encompass direct viral invasion through molecular mimicry/spike (S) protein production, an escalated inflammatory response, hypoxia, myocardial cell death, and the eventual scar/fibrosis. They correspond to a range of conditions including atrial tachyarrhythmias, bradyarrhythmia, ventricular arrhythmias, sudden cardiac death, and the frequently occurring myocarditis. For treating these COVID-19 vaccination-induced arrhythmias, we should incorporate general treatment strategies, similar to those applied to arrhythmias from other causes.
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Affiliation(s)
- Bavithra Pari
- Department of Medicine, LSUHSC-S, Shreveport, LA, USA
| | | | | | - Anuj Thakre
- Department of Medicine, LSUHSC-S, Shreveport, LA, USA
| | | | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, KS, Kansas City, USA
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, The University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Paari Dominic
- Division of Cardiology, Department of Medicine, The University of Iowa, Carver College of Medicine, Iowa City, IA, USA.
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42
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Gomez F, Mehra A, Ensrud E, Diedrich D, Laudanski K. COVID-19: a modern trigger for Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. Front Neurosci 2023; 17:1198327. [PMID: 37712090 PMCID: PMC10498773 DOI: 10.3389/fnins.2023.1198327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/31/2023] [Indexed: 09/16/2023] Open
Abstract
COVID-19 infection has had a profound impact on society. During the initial phase of the pandemic, there were several suggestions that COVID-19 may lead to acute and protracted neurologic sequelae. For example, peripheral neuropathies exhibited distinctive features as compared to those observed in critical care illness. The peripheral nervous system, lacking the protection afforded by the blood-brain barrier, has been a particular site of sequelae and complications subsequent to COVID-19 infection, including Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. We will discuss these disorders in terms of their clinical manifestations, diagnosis, and treatment as well as the pathophysiology in relation to COVID-19.
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Affiliation(s)
- Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Ashir Mehra
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Erik Ensrud
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
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43
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Taş S, Taş Ü. Effects of COVID-19 on the Autonomic Cardiovascular System: Heart Rate Variability and Turbulence in Recovered Patients. Tex Heart Inst J 2023; 50:e227952. [PMID: 37605870 PMCID: PMC10660136 DOI: 10.14503/thij-22-7952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND COVID-19 may be a risk factor for developing cardiovascular autonomic dysfunction. Data are limited, however, on the association between heart rate variability, heart rate turbulence, and COVID-19. The aims of this study were to evaluate the effect of COVID-19 on the cardiovascular autonomic system in patients with persistent symptoms after recovering from COVID-19 and to determine whether these patients showed changes in ambulatory electrocardiography monitoring. METHODS Fifty-one adults who had confirmed SARS-CoV-2 infection and presented with persistent symptoms to the cardiology outpatient clinic after clinical recovery between April and June 2021 were included. Patients were prospectively followed for 6 months. The patients were evaluated at the time of first application to the cardiology outpatient clinic and at 6 months after presentation. Ambulatory electrocardiography monitoring and echocardiographic findings were compared with a control group of 95 patients. RESULTS Patients in the post-COVID-19 group had significantly higher mean (SD) turbulence onset (0.39% [1.82%] vs -1.37% [2.93%]; P < .001) and lower heart rate variability than those in the control group at both initial and 6-month evaluations. The post-COVID-19 group had no significant differences in echocardiographic findings compared with the control group at 6 months, except for right ventricle late diastolic mitral annular velocity (P = .034). Furthermore, turbulence onset was significantly correlated with turbulence slope (r = -0.232; P = .004), heart rate variability, and the parameters of left (r = -0.194; P=.049) and right (r = 0.225; P = .02) ventricular diastolic function. CONCLUSIONS COVID-19 may cause cardiovascular autonomic dysfunction. Heart rate variability and turbulence parameters can be used to recognize cardiovascular autonomic dysfunction in patients who have recovered from COVID-19 but have persistent symptoms.
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Affiliation(s)
- Sedat Taş
- Department of Cardiology, Manisa City Hospital, Manisa, Turkey
| | - Ümmü Taş
- Department of Cardiology, Manisa Merkezefendi State Hospital, Manisa, Turkey
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Gómez-Moyano E, Rodríguez-Capitán J, Gaitán Román D, Reyes Bueno JA, Villalobos Sánchez A, Espíldora Hernández F, González Angulo GE, Molina Mora MJ, Thurnhofer-Hemsi K, Molina-Ramos AI, Romero-Cuevas M, Jiménez-Navarro M, Pavón-Morón FJ. Postural orthostatic tachycardia syndrome and other related dysautonomic disorders after SARS-CoV-2 infection and after COVID-19 messenger RNA vaccination. Front Neurol 2023; 14:1221518. [PMID: 37654428 PMCID: PMC10467287 DOI: 10.3389/fneur.2023.1221518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
The COVID-19 pandemic has caused a challenge for our society due to the post-acute sequelae of the disease. Persistent symptoms and long-term multiorgan complications, known as post-acute COVID-19 syndrome, can occur beyond 4 weeks from the onset of the COVID-19 infection. Postural orthostatic tachycardia syndrome (POTS) is considered a variety of dysautonomia, which is characterized by chronic symptoms that occur with standing and a sustained increase in heart rate, without orthostatic hypotension. POTS can lead to debilitating symptoms, significant disability, and impaired quality of life. In this narrative review, the etiopathogenic basis, epidemiology, clinical manifestations, diagnosis, treatment, prognosis, and socioeconomic impact of POTS, as well as other related dysautonomic disorders, after COVID-19 infection and SARS-CoV-2 postvaccination, were discussed. After a search conducted in March 2023, a total of 89 relevant articles were selected from the PubMed, Google Scholar, and Web of Science databases. The review highlights the importance of recognizing and managing POTS after COVID-19 infection and vaccination, and the approach to autonomic disorders should be known by all specialists in different medical areas. The diagnosis of POTS requires a comprehensive clinical assessment, including a detailed medical history, physical examination, orthostatic vital signs, and autonomic function tests. The treatment of POTS after COVID-19 infection or vaccination is mainly focused on lifestyle modifications, such as increased fluid and salt intake, exercise, and graduated compression stockings. Pharmacotherapy, such as beta-blockers, fludrocortisone, midodrine, and ivabradine, may also be used in selected cases. Further research is needed to understand the underlying mechanisms, risk factors, and optimal treatment strategies for this complication.
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Affiliation(s)
| | - Jorge Rodríguez-Capitán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Daniel Gaitán Román
- Department of Cardiology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | | | - Karl Thurnhofer-Hemsi
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Computer Languages and Computer Sciences, University of Malaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Miguel Romero-Cuevas
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Jiménez-Navarro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Department of Medicine and Dermatology, University of Malaga, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Elbeltagi R, Al-Beltagi M, Saeed NK, Bediwy AS. COVID-19-induced gastrointestinal autonomic dysfunction: A systematic review. World J Clin Cases 2023; 11:5246-5266. [DOI: 10.12998/wjcc.v11.i22.5246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/10/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND It is common for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to occur in the gastrointestinal tract, which can present itself as an initial symptom. The severity of coronavirus disease 2019 (COVID-19) is often reflected in the prevalence of gastrointestinal symptoms. COVID-19 can damage the nerve supply to the digestive system, leading to gastrointestinal autonomic dysfunction. There is still much to learn about how COVID-19 affects the autonomic nervous system and the gastrointestinal tract.
AIM To thoroughly explore the epidemiology and clinical aspects of COVID-19-induced gastrointestinal autonomic dysfunction, including its manifestations, potential mechanisms, diagnosis, differential diagnosis, impact on quality of life, prognosis, and management and prevention strategies.
METHODS We conducted a thorough systematic search across various databases and performed an extensive literature review. Our review encompassed 113 studies published in English from January 2000 to April 18, 2023.
RESULTS According to most of the literature, gastrointestinal autonomic dysfunction can seriously affect a patient's quality of life and ultimate prognosis. Numerous factors can influence gastrointestinal autonomic nervous functions. Studies have shown that SARS-CoV-2 has a well-documented affinity for both neural and gastrointestinal tissues, and the virus can produce various gastrointestinal symptoms by reaching neural tissues through different pathways. These symptoms include anorexia, dysgeusia, heartburn, belching, chest pain, regurgitation, vomiting, epigastric burn, diarrhea, abdominal pain, bloating, irregular bowel movements, and constipation. Diarrhea is the most prevalent symptom, followed by anorexia, nausea, vomiting, and abdominal pain. Although COVID-19 vaccination may rarely induce autonomic dysfunction and gastrointestinal symptoms, COVID-19-induced autonomic effects significantly impact the patient's condition, general health, prognosis, and quality of life. Early diagnosis and proper recognition are crucial for improving outcomes. It is important to consider the differential diagnosis, as these symptoms may be induced by diseases other than COVID-19-induced autonomic dysfunction. Treating this dysfunction can be a challenging task.
CONCLUSION To ensure the best possible outcomes for COVID-19 patients, it is essential to take a multidisciplinary approach involving providing supportive care, treating the underlying infection, managing dysfunction, monitoring for complications, and offering nutritional support. Close monitoring of the patient's condition is crucial, and prompt intervention should be taken if necessary. Furthermore, conducting thorough research on the gastrointestinal autonomic dysfunction caused by COVID-19 is vital to manage it effectively.
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Affiliation(s)
- Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland-Medical University of Bahrain, Busiateen 15503, Muharraq, Bahrain
| | - Mohammed Al-Beltagi
- Department of Paediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Paediatrics, University Medical Center, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Paediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Pathology Department, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 12, Manama, Bahrain
- Microbiology Section, Pathology Department, The Royal College of Surgeons in Ireland-Medical University of Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Disease, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Pulmonology, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
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46
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Elbeltagi R, Al-Beltagi M, Saeed NK, Bediwy AS. COVID-19-induced gastrointestinal autonomic dysfunction: A systematic review. World J Clin Cases 2023; 11:5252-5272. [PMID: 37621592 PMCID: PMC10445067 DOI: 10.12998/wjcc.v11.i22.5252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/10/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND It is common for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to occur in the gastrointestinal tract, which can present itself as an initial symptom. The severity of coronavirus disease 2019 (COVID-19) is often reflected in the prevalence of gastrointestinal symptoms. COVID-19 can damage the nerve supply to the digestive system, leading to gastrointestinal autonomic dysfunction. There is still much to learn about how COVID-19 affects the autonomic nervous system and the gastrointestinal tract. AIM To thoroughly explore the epidemiology and clinical aspects of COVID-19-induced gastrointestinal autonomic dysfunction, including its manifestations, potential mechanisms, diagnosis, differential diagnosis, impact on quality of life, prognosis, and management and prevention strategies. METHODS We conducted a thorough systematic search across various databases and performed an extensive literature review. Our review encompassed 113 studies published in English from January 2000 to April 18, 2023. RESULTS According to most of the literature, gastrointestinal autonomic dysfunction can seriously affect a patient's quality of life and ultimate prognosis. Numerous factors can influence gastrointestinal autonomic nervous functions. Studies have shown that SARS-CoV-2 has a well-documented affinity for both neural and gastrointestinal tissues, and the virus can produce various gastrointestinal symptoms by reaching neural tissues through different pathways. These symptoms include anorexia, dysgeusia, heartburn, belching, chest pain, regurgitation, vomiting, epigastric burn, diarrhea, abdominal pain, bloating, irregular bowel movements, and constipation. Diarrhea is the most prevalent symptom, followed by anorexia, nausea, vomiting, and abdominal pain. Although COVID-19 vaccination may rarely induce autonomic dysfunction and gastrointestinal symptoms, COVID-19-induced autonomic effects significantly impact the patient's condition, general health, prognosis, and quality of life. Early diagnosis and proper recognition are crucial for improving outcomes. It is important to consider the differential diagnosis, as these symptoms may be induced by diseases other than COVID-19-induced autonomic dysfunction. Treating this dysfunction can be a challenging task. CONCLUSION To ensure the best possible outcomes for COVID-19 patients, it is essential to take a multidisciplinary approach involving providing supportive care, treating the underlying infection, managing dysfunction, monitoring for complications, and offering nutritional support. Close monitoring of the patient's condition is crucial, and prompt intervention should be taken if necessary. Furthermore, conducting thorough research on the gastrointestinal autonomic dysfunction caused by COVID-19 is vital to manage it effectively.
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Affiliation(s)
- Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland-Medical University of Bahrain, Busiateen 15503, Muharraq, Bahrain
| | - Mohammed Al-Beltagi
- Department of Paediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Paediatrics, University Medical Center, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Paediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Pathology Department, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 12, Manama, Bahrain
- Microbiology Section, Pathology Department, The Royal College of Surgeons in Ireland-Medical University of Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Disease, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Pulmonology, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
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Copley M, Kozminski B, Gentile N, Geyer R, Friedly J. Postacute Sequelae of SARS-CoV-2: Musculoskeletal Conditions and Pain. Phys Med Rehabil Clin N Am 2023; 34:585-605. [PMID: 37419534 DOI: 10.1016/j.pmr.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
Musculoskeletal and pain sequelae of COVID-19 are common in both the acute infection and patients experiencing longer term symptoms associated with recovery, known as postacute sequelae of COVID-19 (PASC). Patients with PASC may experience multiple manifestations of pain and other concurrent symptoms that complicate their experience of pain. In this review, the authors explore what is currently known about PASC-related pain and its pathophysiology as well as strategies for diagnosis and management.
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Affiliation(s)
- Michelle Copley
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Barbara Kozminski
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Nicole Gentile
- Department of Family Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356390, Seattle, WA 98195-6390, USA; Department of Laboratory Medicine and Pathology, University of Washington, 1959 Northeast Pacific Street Seattle, WA 98195-6390, USA
| | - Rachel Geyer
- Department of Family Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356390, Seattle, WA 98195-6390, USA
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
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48
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Haloot J, Bhavaraju-Sanka R, Pillarisetti J, Verduzco-Gutierrez M. Autonomic Dysfunction Related to Postacute SARS-CoV-2 Syndrome. Phys Med Rehabil Clin N Am 2023; 34:563-572. [PMID: 37419532 DOI: 10.1016/j.pmr.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
Persistence of symptoms beyond the initial acute phase of coronavirus disease-2019 (COVID-19) is termed postacute SARS-CoV-2 (PASC) and includes neurologic, autonomic, pulmonary, cardiac, psychiatric, gastrointestinal, and functional impairment. PASC autonomic dysfunction can present with dizziness, tachycardia, sweating, headache, syncope, labile blood pressure, exercise intolerance, and "brain fog." A multidisciplinary team can help manage this complex syndrome with nonpharmacologic and pharmacologic interventions.
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Affiliation(s)
- Justin Haloot
- Department of Internal Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Ratna Bhavaraju-Sanka
- Department of Neurology, UT Health San Antonio, Joe R. & Theresa Lozano Long School of Medicine, 7703 Floyd Curl Drive, Mail Code 7883, San Antonio, TX 78229, USA.
| | - Jayasree Pillarisetti
- Janey & Dolph Briscoe Division of Cardiology, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Joe R. & Teresa Lozano Long School of Medicine, UT Health at San Antonio Texas, 7703 Floyd Curl Drive, Room 628E, San Antonio, TX 78229, USA
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Nguyen T, Wanjala SS, Brake MB. Management of Labile Blood Pressure due to COVID-19 Infection and Radiation Induced Baroreceptor Dysfunction. Kans J Med 2023; 16:182-184. [PMID: 37539372 PMCID: PMC10395768 DOI: 10.17161/kjm.vol16.19691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/22/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Timothy Nguyen
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Stephen S Wanjala
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Mona B Brake
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
- Robert J. Dole Veterans Affairs Medical Center, Wichita, KS
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Schnekenberg L, Sedghi A, Schoene D, Pallesen LP, Barlinn J, Woitek F, Linke A, Puetz V, Barlinn K, Mangner N, Siepmann T. Assessment and Therapeutic Modulation of Heart Rate Variability: Potential Implications in Patients with COVID-19. J Cardiovasc Dev Dis 2023; 10:297. [PMID: 37504553 PMCID: PMC10380874 DOI: 10.3390/jcdd10070297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023] Open
Abstract
Cardiac damage has been attributed to SARS-CoV-2-related pathology contributing to increased risk of vascular events. Heart rate variability (HRV) is a parameter of functional neurocardiac integrity with low HRV constituting an independent predictor of cardiovascular mortality. Whether structural cardiac damage translates into neurocardiac dysfunction in patients infected with SARS-CoV-2 remains poorly understood. Hypothesized mechanisms of possible neurocardiac dysfunction in COVID-19 comprise direct systemic neuroinvasion of autonomic control centers, ascending virus propagation along cranial nerves and cardiac autonomic neuropathy. While the relationship between the autonomic nervous system and the cytokine cascade in general has been studied extensively, the interplay between the inflammatory response caused by SARS-CoV-2 and autonomic cardiovascular regulation remains largely unclear. We reviewed the current literature on the potential diagnostic and prognostic value of autonomic neurocardiac function assessment via analysis of HRV including time domain and spectral analysis techniques in patients with COVID-19. Furthermore, we discuss potential therapeutic targets of modulating neurocardiac function in this high-risk population including HRV biofeedback and the impact of long COVID on HRV as well as the approaches of clinical management. These topics might be of particular interest with respect to multimodal pandemic preparedness concepts.
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Affiliation(s)
- Luiz Schnekenberg
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Felix Woitek
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Axel Linke
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Norman Mangner
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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