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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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2
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Pelling MM, Brown MT, Gilliland CA, Cutchins A. Left Common Iliac Vein Stenting in a Case of Postural Orthostatic Tachycardia Syndrome/Pelvic Pain Overlap. Cureus 2024; 16:e53974. [PMID: 38469013 PMCID: PMC10927248 DOI: 10.7759/cureus.53974] [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] [Accepted: 02/09/2024] [Indexed: 03/13/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is mainly characterized by orthostatic intolerance and positional tachycardia although it frequently involves a myriad of non-specific symptoms that seem to overlap with existing medical conditions. Recent efforts have been made to further classify subtypes of POTS and associated conditions to better delineate underlying pathophysiology in an effort to guide diagnosis and tailor treatment. Here, we present a 22-year-old female with debilitating symptoms of POTS who reported pelvic pain on review of systems and underwent vascular ultrasound of the inferior vena cava, iliac veins, and bilateral lower extremities which revealed the characteristic left common iliac vein compression of May-Thurner syndrome prompting venous stenting which provided systemic symptomatic relief.
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Affiliation(s)
- Mary M Pelling
- Internal Medicine, Emory University School of Medicine, Atlanta, USA
| | - Matthew T Brown
- Cardiology, Emory University School of Medicine, Atlanta, USA
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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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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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Hira R, Baker JR, Siddiqui T, Ranada SI, Soroush A, Karalasingham K, Ahmad H, Mavai V, Ayala Valani LM, Ambreen S, Bourne KM, Lloyd MG, Morillo CA, Sheldon RS, Raj SR. Objective Hemodynamic Cardiovascular Autonomic Abnormalities in Post-Acute Sequelae of COVID-19. Can J Cardiol 2023; 39:767-775. [PMID: 36509178 PMCID: PMC9733966 DOI: 10.1016/j.cjca.2022.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many COVID-19 patients are left with symptoms several months after resolution of the acute illness; this syndrome is known as post-acute sequalae of COVID-19 (PASC). We aimed to determine the prevalence of objective hemodynamic cardiovascular autonomic abnormalities (CAA), explore sex differences, and assess the prevalence of CAA among hospitalized vs nonhospitalized patients with PASC. METHODS Patients with PASC (n = 70; female [F] = 56; 42 years of age; 95% confidence interval [CI], 40-48) completed standard autonomic tests, including an active stand test 399 days (338, 455) after their COVID-19 infection. Clinical autonomic abnormalities were evaluated. RESULTS Most patients with PASC met the criteria for at least 1 CAA (51; 73%; F = 43). The postural orthostatic tachycardia syndrome hemodynamic (POTSHR) criterion of a heart rate increase of > 30 beats per minute within 5 to 10 minutes of standing was seen in 21 patients (30%; F = 20; P = 0.037 [by sex]). The initial orthostatic hypotension hemodynamic (IOH40) criterion of a transient systolic blood pressure change of > 40 mm Hg in the first 15 seconds of standing was seen in 43 (61%) patients and equally among female and male patients (63% vs 57%; P = 0.7). Only 9 (13%) patients were hospitalized; hospitalized vs nonhospitalized patients had similar frequencies of abnormalities (67% vs 74%; P = 0.7). CONCLUSIONS Patients with PASC have evidence of CAA, most commonly IOH40, which will be missed unless an active stand test is used. Female patients have increased frequency of POTSHR, but IOH40 is equally prevalent between sexes. Finally, even nonhospitalized "mild" infections can result in long-term CAAs.
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Affiliation(s)
- Rashmin Hira
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jacquie R Baker
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanya Siddiqui
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shaun I Ranada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ateyeh Soroush
- Department of Neuroscience, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kavithra Karalasingham
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hyeqa Ahmad
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vibhuti Mavai
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luciano Martin Ayala Valani
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sakina Ambreen
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew G Lloyd
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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van Campen C(LMC, Visser FC. Long-Haul COVID Patients: Prevalence of POTS Are Reduced but Cerebral Blood Flow Abnormalities Remain Abnormal with Longer Disease Duration. Healthcare (Basel) 2022; 10:healthcare10102105. [PMID: 36292552 PMCID: PMC9602558 DOI: 10.3390/healthcare10102105] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Postural orthostatic tachycardia syndrome (POTS) has been described early after the onset of the COVID-19 infection, but also orthostatic hypotension (OH). In the present study, we hypothesized that orthostatic intolerance decreases over time. Methods: In 29 long-haul COVID-19 (LHC) patients, a tilt test was performed, including measurements of cerebral blood flow (CBF) by extracranial Doppler. The time interval between the onset of infection and the tilt test varied between 3 and 28 months. Results: In the first 12 months after the infection, 71% of the LHC patients showed POTS and after 24 months none of them. In the first 12 months, 29% of patients had a normal heart rate and blood pressure response (normHRBP) and after 24 months 75% (distribution of POTS, OH, and a normHRBP over time: p < 0.0001). Linear regression showed that, over time, there was a decrease in the abnormal CBF during the tilt (p = 0.024) but remained abnormal. Conclusion: In LHC patients, hemodynamic abnormalities of a tilt test change over time. Patients studied early after the onset of the disease mainly exhibit POTS, but patients studied later in the time course mainly show a normHRBP or OH. In addition, the abnormal CBF reduction improves over time, but CBF remains abnormal.
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