Review nature reviews cardiology: Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health care burden, Fedorowski et al, 2024

nature reviews cardiology Cardiovascular autonomi dysfunction in post-COVID-19 syndrome: a major health-care burden, Fedorowski et al


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.

Key points

• Cardiovascular autonomic dysfunction (CVAD), in particular postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia, are among the most frequent and distinct phenotypes of post-COVID-19 syndrome; one-third of highly symptomatic patients can be affected.
  
  
• CVAD arises from a malfunction of the autonomic control of the circulation, and can involve failure or inadequate or excessive activation of the sympathetic and parasympathetic components of the autonomic nervous system.
  
  
• As well as global circulatory disturbances, CVAD in post-COVID-19 syndrome can manifest as microvascular and endothelial dysfunction, with local symptoms such as headache, brain fog, chest pain, dyspnoea and peripheral circulatory symptoms, including skin discolouration, oedema, Raynaud-like phenomena, and heat and cold intolerance.
  
  
• A structured diagnostic work-up based on a detailed patient history, cardiovascular autonomic testing, long-term electrocardiogram and blood-pressure monitoring, and ancillary cardiac and peripheral vascular tests will lead to an appropriate diagnosis.
  
  
• Management of CVAD in post-COVID-19 syndrome should involve a correct diagnosis, patient education, and both non-pharmacological and pharmacological methods; a tailored exercise training programme, blood volume expansion and compression garments are especially effective.
  
  
• Pharmacological approaches target heart rate control, blood volume expansion, promotion of vasoconstriction and venoconstriction, and reduction of hyperadrenergic drive.
  

 

Link to full article which was shared by the first author on Twitter. Haven't read it, but see that ME is mentioned in the introduction

ETA:

quote:

- We are at the early stages of understanding long COVID and the associated cardiovascular autonomic dysfunction (CVAD), but it seems to be similar to other post-viral syndromes9,10. In particular, there is sub-stantial overlap with myalgic encephalitis/chronic fatigue syndrome (ME/CFS), a condition that is frequently encountered in both long COVID1,11 and postural orthostatic tachycardia syndrome (POTS)12. As in many post-viral syndromes, CVAD in patients with long COVID often seems to be worse than the COVID-19 itself, and the severity of the CVAD might not correlate with that of the initial infection9.

 

comment from neurologist Michael Stingl on Twitter (translated from German):

A good overview of the diagnosis and treatment of cardiovascular dysautonomia, e.g. POTS, in the context of Long Covid. ME/CFS and PEM are explicitly mentioned, but at the same time PACE is cited. Here you have to follow guidelines like those of
@NICEComms !

ETA

where PACE is referenced in the review article:

We recommend the use of a rowing machine or a recumbent cycle for 30-min sessions at least four times per week157. The exercise should be graded, starting slowly and at a low load. Patients are likely to feel worse initially and might not improve for 4–6 weeks. Application of graded exercise therapy is especially important in the setting of coexistent ME/CFS to reduce the effects of the highly expected post-exertional malaise158.

 

Sickening.

 

I left a comment on LinkedIn about it. Let's see what the lead author has to say about that graded exercise therapy bit.

https://www.linkedin.com/feed/updat...41694976,urn:li:activity:7147894810144673792)

 

you can ask him here:
https://twitter.com/user/status/1742128377052504450

 

https://twitter.com/user/status/1746659778623951152

 

Given that 2 years ago Mango reported, about a different paper, that

he really shouldn't be now claiming ignorance around the issue of GET and PACE.

 

I agree 100%!

 

Somebody has asked him about the GET/PACE part on his Facebook post about the study too. No reply so far

 

Peer review information
Nature Reviews Cardiology thanks Svetlana Blitshteyn, David Goldstein and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

 

Unfortunately Dr Fedorowski does not seem open to hearing about the flaws of the PACE trial. He has been blocking people who pointed them out, such as Dr Todd Davenport of the Workwell Foundation, and has hidden replies under his tweet about the article.

https://twitter.com/user/status/1747238757093544403

 

Absolutely shocking!

 

Gotta love that patient-centered medicine thingy. You can just feel how centered it is.

 

In his defence Twitter can be a very aggressive medium, where harassment is a very close cousin to justified criticism. I suppose there might be better places to discuss such things than social media (email often seems more fruitful).

 

Funny how they have no problem dishing it out and ruining our lives with their writings but a little bit of heat comes their way on Twitter and they run away from confrontation.

 

Another excellent blog article by @MittEremltage, well worth a read. Thank you!

PACE-klet i vetenskaplig artikel om POTS
https://mitteremitage.wordpress.com/2024/01/21/pace-klet-i-vetenskaplig-artikel-om-pots/