Dysautonomia in COVID-19 Patients: A Narrative Review on Clinical Course, Diagnostic and Therapeutic Strategies

Abstract

IntroductionOn March 11, 2020, the World Health Organization sounded the COVID-19 pandemic alarm. While efforts in the first few months focused on reducing the mortality of infected patients, there is increasing data on the effects of long-term infection (Post-COVID-19 condition). Among the different symptoms described after acute infection, those derived from autonomic dysfunction are especially frequent and limiting.ObjectiveTo conduct a narrative review synthesizing current evidence of the signs and symptoms of dysautonomia in patients diagnosed with COVID-19, together with a compilation of available treatment guidelines.ResultsAutonomic dysfunction associated with SARS-CoV-2 infection occurs at different temporal stages. Some of the proposed pathophysiological mechanisms include direct tissue damage, immune dysregulation, hormonal disturbances, elevated cytokine levels, and persistent low-grade infection. Acute autonomic dysfunction has a direct impact on the mortality risk, given its repercussions on the respiratory, cardiovascular, and neurological systems. Iatrogenic autonomic dysfunction is a side effect caused by the drugs used and/or admission to the intensive care unit. Finally, late dysautonomia occurs in 2.5% of patients with Post-COVID-19 condition. While orthostatic hypotension and neurally-mediated syncope should be considered, postural orthostatic tachycardia syndrome (POTS) appears to be the most common autonomic phenotype among these patients. A review of diagnostic and treatment guidelines focused on each type of dysautonomic condition was done.ConclusionSymptoms deriving from autonomic dysfunction involvement are common in those affected by COVID-19. These symptoms have a great impact on the quality of life both in the short and medium to long term. A better understanding of the pathophysiological mechanisms of Post-COVID manifestations that affect the autonomic nervous system, and targeted therapeutic management could help reduce the sequelae of COVID-19, especially if we act in the earliest phases of the disease.

Post-COVID Syndrome in Adults—An Overview

“…Some of the symptoms displayed in Figure 1 are likely to be due to dysautonomia [ 14 ]. Autonomic dysfunction appears to be a rather frequent feature of the post-COVID condition and can cause, for example, orthostatic intolerance syndromes, neurogenic orthostatic hypotension, labile blood pressure, postural orthostatic tachycardia syndrome [ 15 ], and other more non-specific sequelae, such as gastrointestinal symptoms (e.g., abdominal pain, vomiting, constipation, or loose stools), flushing, sweating abnormalities, or temperature intolerance [ 14 ].…”

“Long Haulers”

“…Autonomic dysfunction including POTS and neurogenic orthostatic hypotension have been frequently observed in post-COVID-19 patients as well as in the setting of other viral infections. [110][111][112][113] A systemic review reported that approximately 2.5% of patients with COVID-19 infection develop autonomic dysfunction. 110 Jamal et al evaluated 24 patients with symptoms of poor exercise intolerance, tachycardia with activity or positional changes, and palpitations 5.8 AE 3.5 months following acute infection.…”

“…[110][111][112][113] A systemic review reported that approximately 2.5% of patients with COVID-19 infection develop autonomic dysfunction. 110 Jamal et al evaluated 24 patients with symptoms of poor exercise intolerance, tachycardia with activity or positional changes, and palpitations 5.8 AE 3.5 months following acute infection. 114 Head-up tilt table testing was performed with 23 of 24 patients demonstrating orthostatic intolerance.…”

Neurological post‐acute sequelae of SARS‐CoV‐2 infection

“…Standard treatment of POTS is well described and established. 144 With a diagnosis of POTS, we first recommend fluid replacement (2-3 liter of water per day, avoiding caffeine and alcohol). Additionally, we try saline infusion, 1-2 L/day.…”