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Silva MGS, Carvalho TL, de Azevedo Vieira JE, da Costa LR, da Silva DLO, Costa ALB, dos Anjos HPS, Lopes AJ. Evaluating performance on the Glittre-ADL test in men with long COVID 3 years after a SARS-CoV-2 infection. J Exerc Sci Fit 2024; 22:271-277. [PMID: 38601317 PMCID: PMC11002684 DOI: 10.1016/j.jesf.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
Background/objective Many COVID-19 survivors, especially those who have been hospitalized, have been suffering numerous complications that limit their activities of daily living, although changes that persist 3 years after infection are still not known. We aimed to investigate the impact of long COVID on the Glittre-ADL test (TGlittre) 3 years after acute infection in men who needed hospitalization and explore whether the performance on the TGlittre is associated with impairments in lung function, muscle strength, physical function and quality of life (QoL). Methods Cross-sectional study with 42 men with long COVID who took the TGlittre. They underwent pulmonary function tests and measurements of handgrip strength and quadriceps strength (QS). Additionally, they also completed the Saint George Respiratory Questionnaire (SGRQ) and Functional Independence Measure (FIM). Results The mean age was 52 ± 10.6 years, while the mean time after diagnosis of COVID-19 was 37 ± 3.5 months. The mean TGlittre time was 3.3 (3.1-4.1) min, which was 10% greater than the time expected for normal individuals to complete it. The TGlittre time was correlated significantly with the QS (rs = -0.397, p = 0.009), pulmonary diffusion (rs = - 0.364, p = 0.017), FIM (rs = -0.364, p = 0.017) and the "activity" domain score of the SGRQ (rs = 0.327, p = 0.034). Conclusion Functional capacity on exertion as measured by the TGlittre time is normal in most men with long COVID 3 years after hospitalization. However, this improvement in functional capacity does not seem to be reflected in muscle strength or QoL, requiring continued monitoring even after 3 years.
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Affiliation(s)
- Mayra Gomes Soares Silva
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | - Thiago Lemos Carvalho
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | | | | | | | | | | | - Agnaldo José Lopes
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
- Medical Sciences Post-Graduation Program, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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2
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Seeley MC, O'Brien H, Gallagher C, Schild C, Lau DH. Autonomic dysfunction in post-acute sequelae of COVID-19. Eur J Intern Med 2024:S0953-6205(24)00278-4. [PMID: 38981767 DOI: 10.1016/j.ejim.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/16/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia
| | - Howard O'Brien
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia
| | - Caelum Schild
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia; South Australian Health and Medical Research Institute, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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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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Liviero F, Scapellato ML, Volpin A, Battistella M, Fabris L, Brischigliaro L, Folino F, Moretto A, Mason P, Pavanello S. Long term follow-up of heart rate variability in healthcare workers with mild COVID-19. Front Neurol 2024; 15:1403551. [PMID: 38827576 PMCID: PMC11141692 DOI: 10.3389/fneur.2024.1403551] [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: 03/19/2024] [Accepted: 04/17/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Prior investigations into post-COVID dysautonomia often lacked control groups or compared affected individuals solely to healthy volunteers. In addition, no data on the follow-up of patients with SARS-CoV-2-related autonomic imbalance are available. Methods In this study, we conducted a comprehensive clinical and functional follow-up on healthcare workers (HCWs) with former mild COVID-19 (group 1, n = 67), to delineate the trajectory of post-acute autonomic imbalance, we previously detected in a case-control study. Additionally, we assessed HCWs for which a test before SARS-CoV-2 infection was available (group 2, n = 29), who later contracted SARS-CoV-2, aiming to validate findings from our prior case-control investigation. We evaluated autonomic nervous system heart modulation by means of time and frequency domain heart rate variability analysis (HRV) in HCWs during health surveillance visits. Short-term electrocardiogram (ECG) recordings, were obtained at about 6, 13 months and both at 6 and 13 months from the negative SARS-CoV-2 naso-pharyngeal swab (NPS) for group 1 and at about 1-month from the negative NPS for group 2. HCWs who used drugs, had comorbidities that affected HRV, or were hospitalized with severe COVID-19 were excluded. Results Group 1 was split into three subgroups clinically and functionally followed at, about 6 months (subgroup-A, n = 17), 13 months (subgroup-B, n = 37) and both at 6 and 13 months (subgroup-C, n = 13) from the negative SARS-CoV-2 NPS. In subgroup-A, at 6-month follow-up compared with baseline, the spectral components in the frequency domain HRV parameters, showed an increase in normalized high frequency power (nHF) (t = 2.99, p = 0.009), a decrease in the normalized low frequency power (nLF) (t = 2.98, p = 0.009) and in the LF/HF ratio (t = 3.13, p = 0.006). In subgroup B, the comparison of the spectral components in the frequency domain HRV parameters, at 13-month follow-up compared with baseline, showed an increase in nHF (t = 2.54, p = 0.02); a decrease in nLF (t = 2.62, p = 0.01) and in the LF/HF ratio (t = 4.00, p = 0.0003). In subgroup-C, at both 6 and 13-month follow-ups, the spectral components in the frequency domain HRV parameters were higher than baseline in nHF (t = 2.64, p = 0.02 and (t = 2.13, p = 0.05, respectively); lower in nLF (t = 2.64, p = 0.02 and (t = 2.13, p = 0.05, respectively), and in LF/HF (t = 1.92, p = 0.08 and (t = 2.43, p = 0.03, respectively). A significant proportion of HCWs reported persistent COVID-19 symptoms at both the 6 and 13-month follow-ups, seemingly unrelated to cardiac autonomic balance. In group 2 HCWs, at 1-month follow-up compared with baseline, the spectral components in the frequency domain HRV parameters, showed a decrease in nHF (t = 2.19, p = 0.04); an increase in nLF (t = 2.15, p = 0.04) and in LF/HF (t = 3.49, p = 0.002). Conclusion These results are consistent with epidemiological data suggesting a higher risk of acute cardiovascular complications during the first 30 days after COVID-19. The SARS-CoV-2 associated autonomic imbalance in the post-acute phase after recovery of mild COVID-19 resolved 6 months after the first negative SARS-CoV-2 NPS. However, a significant proportion of HCWs reported long-term COVID-19 symptoms, which dot not seems to be related to cardiac autonomic balance. Future research should certainly further test whether autonomic imbalance has a role in the mechanisms of long-COVID syndrome.
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Affiliation(s)
- Filippo Liviero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Maria Luisa Scapellato
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Anna Volpin
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Monica Battistella
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Laura Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Laura Brischigliaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Franco Folino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Angelo Moretto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Paola Mason
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
| | - Sofia Pavanello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Occupational Medicine Unit, University Hospital of Padova, Padova, Italy
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Lee C, Greenwood DC, Master H, Balasundaram K, Williams P, Scott JT, Wood C, Cooper R, Darbyshire JL, Gonzalez AE, Davies HE, Osborne T, Corrado J, Iftekhar N, Rogers N, Delaney B, Greenhalgh T, Sivan M. Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study. J Med Virol 2024; 96:e29486. [PMID: 38456315 DOI: 10.1002/jmv.29486] [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: 12/27/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
Orthostatic intolerance (OI), including postural orthostatic tachycardia syndrome (PoTS) and orthostatic hypotension (OH), are often reported in long covid, but published studies are small with inconsistent results. We sought to estimate the prevalence of objective OI in patients attending long covid clinics and healthy volunteers and associations with OI symptoms and comorbidities. Participants with a diagnosis of long covid were recruited from eight UK long covid clinics, and healthy volunteers from general population. All undertook standardized National Aeronautics and Space Administration Lean Test (NLT). Participants' history of typical OI symptoms (e.g., dizziness, palpitations) before and during the NLT were recorded. Two hundred seventy-seven long covid patients and 50 frequency-matched healthy volunteers were tested. Healthy volunteers had no history of OI symptoms or symptoms during NLT or PoTS, 10% had asymptomatic OH. One hundred thirty (47%) long covid patients had previous history of OI symptoms and 144 (52%) developed symptoms during the NLT. Forty-one (15%) had an abnormal NLT, 20 (7%) met criteria for PoTS, and 21 (8%) had OH. Of patients with an abnormal NLT, 45% had no prior symptoms of OI. Relaxing the diagnostic thresholds for PoTS from two consecutive abnormal readings to one abnormal reading during the NLT, resulted in 11% of long covid participants (an additional 4%) meeting criteria for PoTS, but not in healthy volunteers. More than half of long covid patients experienced OI symptoms during NLT and more than one in 10 patients met the criteria for either PoTS or OH, half of whom did not report previous typical OI symptoms. We therefore recommend all patients attending long covid clinics are offered an NLT and appropriate management commenced.
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Affiliation(s)
- Cassie Lee
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Harsha Master
- Covid Assessment and Rehabilitation Service, Hertfordshire Community NHS Trust, Welwyn Garden City, UK
| | - Kumaran Balasundaram
- NIHR Leicester Biomedical Research Centre, Respiratory & Infection Theme, Glenfield Hospital, Leicester, UK
| | - Paul Williams
- Covid Assessment and Rehabilitation Service, Hertfordshire Community NHS Trust, Welwyn Garden City, UK
| | - Janet T Scott
- Development and Innovation Department, NHS Highlands, Inverness, UK
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Conor Wood
- Birmingham Community Healthcare, Birmingham, UK
| | - Rowena Cooper
- Development and Innovation Department, NHS Highlands, Inverness, UK
| | - Julie L Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, UK
| | - Thomas Osborne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Joanna Corrado
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Nafi Iftekhar
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | | | - Brendan Delaney
- Department of Surgery & Cancer, Imperial College, Faculty of Medicine, London, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Manoj Sivan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
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6
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Quinn J. Long COVID autonomic syndrome: Improved understanding through translational research. Eur J Intern Med 2024; 120:34-35. [PMID: 38057245 DOI: 10.1016/j.ejim.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Affiliation(s)
- James Quinn
- Research Compliance Office, Stanford University, 1705 El Camino Real, MC: 5579, Palo Alto, CA 94306, United States.
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7
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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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8
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Jiang Y, Cheng Y, Xiao J, Wang Y, Chen G, Zhang Y. Analysis of the correlation between heart rate variability and palpitation symptoms in female patients with long COVID. Front Cardiovasc Med 2023; 10:1273156. [PMID: 38045913 PMCID: PMC10690811 DOI: 10.3389/fcvm.2023.1273156] [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: 08/07/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
Objectives To analyze the correlation between heart rate variability (HRV) and palpitation symptoms in female patients with long COVID. Methods A total of 272 female healthcare workers who were infected with SARS-CoV-2 for the first time in December 2022 at Fuzhou First Hospital affiliated with Fujian Medical University, were selected as study subjects. These subjects were divided into three groups based on their symptoms: a group with palpitations (70 cases), a group without palpitations but with other symptoms (124 cases), and a group consisting of asymptomatic cases (78 cases). The study compared the general information, COMPASS-31 scores, quality of life scores, and HRV parameters among the three groups. Furthermore, it analyzed the factors influencing palpitation symptoms in female patients with long COVID. Results Compared to the other two groups, the HRV parameters SDNN, HRVIndex, LF, and TP were significantly reduced in the group with palpitations (p < 0.05). Multivariate analysis revealed that HRVIndex (p = 0.016; OR: 0.966, 95% CI: 0.940∼0.994) had a significant impact on palpitation symptoms in female patients with long COVID. Conclusions The symptoms of palpitations in female patients with long COVID were found to be related to HRV parameters. Autonomic dysfunction may be connected to the occurrence of palpitation symptoms in long COVID.
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Affiliation(s)
- Yu Jiang
- Department of Cardiovascular Medicine, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
- Cardiovascular Disease Research Institute of Fuzhou City, Fuzhou, China
| | - Yan Cheng
- Department of Cardiovascular Medicine, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
- Cardiovascular Disease Research Institute of Fuzhou City, Fuzhou, China
| | - Jingwen Xiao
- Department of Cardiovascular Medicine, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
- Cardiovascular Disease Research Institute of Fuzhou City, Fuzhou, China
| | - Yicheng Wang
- Department of Cardiovascular Medicine, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
- Cardiovascular Disease Research Institute of Fuzhou City, Fuzhou, China
| | - Geng Chen
- Department of Nursing, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
| | - Yan Zhang
- Department of Cardiovascular Medicine, Fuzhou First Hospital Affiliated with Fujian Medical University, Fuzhou, China
- Cardiovascular Disease Research Institute of Fuzhou City, Fuzhou, China
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