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Cardiovascular Autonomic
Dysfunction in the Post-COVID
Landscape: Detection and
Management
Senior Consultant & Associate Professor
Syncope and Dysautonomia Unit
Karolinska University Hospital
Artur Fedorowski, MD, PhD
Cardiovascular Autonomic Dysfunction in the Post-
COVID Landscape:
Detection and Management
Feb 23, 2023
Artur Fedorowski
MD, PhD, Assoc. Prof., FESC
Dept. of Cardiology, Karolinska University Hospital, Stockholm, Sweden
How did it all begin?
Unexplained post-
COVID symptoms
• Active and healthy 41-year-old
woman (mild asthma only), married,
two children, a team leader in an
educational institution.
• She fell ill with suspected COVID-19
infection in March 2020 and
developed chronic fatigue,
palpitations, orthostatic intolerance,
problems with concentration and GI
symptoms;
Unexplained post-
COVID symptoms
• She was examined with CT
thorax/abdomen (July -20),
echocardiography (July -20), Holter
ECG (August -20), spirometry with
DLCO (Sep-20) and panel of
laboratory tests with normal results
except for slightly elevated average
24h heart rate of 89 bpm (66-153).
Cardiac MRI normal.
• Referred to the autonomic lab at
university hospital in Malmö (S)
Active standing test (beat-to-beat)
155 bpm
Blood pressure
Heart rate
-40 mmHg
Lightheadedness
Standing
Valsalva maneuvre
Blood pressure
Heart rate
“Overshoot”
Tilt testing
135 bpm
Blood pressure
Heart rate
Lightheadedness Deep breathing test
Blood pressure
oscillations
Interpretation of CV autonomic tests
• Pathologic active standing test (sinus tachycardia = POTS; BP fall = initial
orthostatic hypotension)
• Pathologic Valsalva (hyperadrenergic response = frequently seen in POTS)
• Pathologic tilt testing (sinus tachycardia max 143 bpm with symptom
reproduction) = POTS dx confirmed (so called “hyperadrenergic type”)
• Normal deep breathing response = normal parasympathetic control
Johansson M et al. J Am Coll Cardiol Case Rep (2021); 3:573-580.
Post Acute COVID Syndrome (PACS)/ Long COVID
1Post-acute COVID-19 is defined as persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of infection.
1 Nalbandian, A. et al. Nat Med 27, 601–615 (2021)
2 Ballering, A. et al. Lancet 400, 452-61 (2022)
3 Raman, B. et al. Eur Heart J 43, 1157-1172 (2022)
10-15% of COVID-19 patients
develop chronic symptoms2
Major symptoms of PACS/Long
COVID are now recognized as
POTS3
Up to 30% of highly-symptomatic
long COVID patients suffer from
POTS and related CV
dysautonomias3
How big is the problem?
12
10-15%
Young and Middle-aged Women overrepresented
”Long COVID is an often debilitating illness that occurs in at least 10% of severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) infections…At least 65 million individuals worldwide are estimated to have long COVID, with cases increasing daily …Long
COVID encompasses multiple adverse outcomes, with common new-onset conditions including cardiovascular, thrombotic and
cerebrovascular disease, type 2 diabetes, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and dysautonomia,
especially postural orthostatic tachycardia syndrome (POTS)”
Davis HE et al. Nat Rev Microbiol (2023); https://doi.org/10.1038/s41579-022-00846-2
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Definition of dysautonomia/ autonomic dysfunction
a disorder of the autonomic nervous system that causes disturbances in all
or some autonomic functions and may result from the course of a disease
(as diabetes) or from injury or poisoning
Merriam-Webster Dictionary (merriam-webster.com)
Typical manifestations of post-acute COVID-
19 syndrome-related cardiovascular
autonomic dysfunction.
POTS and inappropriate sinus tachycardia are
the most prevalent phenotypes, found in
~30% of highly symptomatic patients.
Global and local symptoms usually
coexist. Wide spectrum of overlapping
symptoms create a diagnostic dilemma
for many doctors.
Fedorowski, A., Sutton, R. Nat Rev
Cardiol (2023)
Canadian Journal of Cardiology DOI: (10.1016/j.cjca.2022.12.002)
Hira R et al. Canadian Journal of Cardiology (2022) DOI: 10.1016/j.cjca.2022.12.002
POTS 21/70
Canadian Journal of Cardiology DOI: (10.1016/j.cjca.2022.12.002)
Hira R et al. Canadian Journal of Cardiology (2022) DOI: 10.1016/j.cjca.2022.12.002
POTS 21/70
Cardiovascular Autonomic Testing (CAT):
 Active stand test (beat-to-beat)
 Deep breathing test
 Valsalva maneuvre
 Quantitative sudomotor axon reflex testing
o Tilt testing
o Holter ECG
o 24h-ambulatory BP monitoring
Prevalence and clinical impact of Postural Orthostatic Tachycardia Syndrome in
non-hospitalised patients with post-acute COVID-19 syndrome (PACS)
 Non-hospitalised PACS-patients (n=365) recruited from the Long-COVID outpatient clinic at
Karolinska University Hospital 2020-2022
 117/365 diagnosed with POTS (32%) using active standing test or tilt testing
 PACS + POTS had shorter walking distance in the 6-minute-walk-test (-92m, p<0.001)
 PACS + POTS had lower self-assessed quality of life on the EuroQol-5D-Visual analogue scale (-9.8
points; p<0.001)
Björnson M, Ståhlberg M, Fedorowski A, Bruchfeld J, et al. Manuscript in preparation.
How to detect cardiovascular autonomic
dysfunction in PACS?
Mayuga K, Fedorowski A et al. Circulation: Arrhythmia and Electrophysiology. Sinus Tachycardia: a
Multidisciplinary Expert Focused Review. 2022; 15 (9): e007960, DOI: (10.1161/CIRCEP.121.007960)
20
Spahic JIM. 2023.Online.
https://doi.org/10.1111/joim.13566
ARTUR FEDOROWSKI, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Common POTS Symptoms
0 Cardiovascular
 Palpitations
 Lightheadedness
 Chest discomfort/pain
 Shortness of breath
 Exercise intolerance
0 NeuroMuscular
 Mental clouding (brain
fog)
 Headaches (migraine)
 Sleep complaints
 Involuntary movements
Gastrointestinal
Nausea and vomiting
Constipation
Weight loss
Chronic Fatigue
Visceral and regional pain
Dysuria
Multiple symptoms associated with
orthostatic intolerance, fatigue and
postural tachycardia
Fedorowski A. JIM 2019;285(4):352-66.
ARTUR FEDOROWSKI, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
How to understand and “measure” dysautonomic symptoms?
Spahic J et al. J Intern Med (2023);293:91-99.
 Although not always “visible”, the symptom
burden is significant, often debilitating.
 Cardiovascular and non-cardiovascular
symptoms may be equally distributed.
 Healthy controls differ from POTS patients
in every symptom category.
Mayuga K, Fedorowski A et al. Circulation: Arrhythmia and Electrophysiology. Sinus Tachycardia: a
Multidisciplinary Expert Focused Review. 2022; 15 (9): e007960, DOI: (10.1161/CIRCEP.121.007960)
23
Spahic JIM. 2023.Online.
https://doi.org/10.1111/joim.13566
www.escardio.org/guidelines
Basic cardiovascular autonomic function tests
 Active standing.
 Valsalva manoeuvre & deep breathing.
 Carotid sinus massage.
 Tilt testing.
 Ambulatory BP monitoring.
 ECG monitoring
Cardiovascular
Autonomic
Laboratory
2018 ESC Guidelines on Syncope – Michele Brignole & Angel Moya
European Heart Journal (2018) 39, 1883–1948
Active standing test
Woman, 20 yo, EDS and POTS, unexplained syncope
standing sitting
supine
Initial
Orthostatic
Hypotension
SBP⇣ >40mmHg
<30 sec
Valsalva test
Man, 37 yo, unexplained syncope
START STOP
sitting
Pathologic
reaction:
No overshoot
No HR reaction
ANS damage
Deep breathing test (1 min)
Woman, 31 yo, POTS
Normal respons
Woman, 27 yo, POTS
Pathologic response
(no oscillations)
Woman, 15 yo, orthostatic intolerance
1. Tilt testing for POTS/OH/VVS
Woman, 52y; prolonged post-COVID symptoms
“normal Holter ECG”
POTS with inappropriate sinus tachycardia
106 bpm
Heart rate ”spikes” and increased heart rate on average
2. Holter ECG for POTS/IST
Ståhlberg M et al. The American journal of medicine. 2021;134(12):1451-6.
Woman, 47y; post-COVID syndrome and syncope
POTS with spontaneous hypotensive tendency
76 mmHg
Unexpected BP drops that are easily interpreted
as artefacts or erroneous BP measurements
Rivasi et al. Eur Heart J 2022; https://doi.org/10.1093/eurheartj/ehac347.
3. 24h ABPM for POTS/OH/VVS
 Low-BP phenotype
 Hypotensive tendency
 Disruption of circadian rhythm
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Mahdi A et al Nov 5-7 2022 AHA Sessions Abstract Oral Presentation
Endothelial and microvascular dysfunction in post-COVID POTS
No MVD in cMRI in control group
4. In the pipeline …
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Tissue responses to activation of specific adrenergic receptor subtypes
Gerald W. Dorn II Physiol Rev 2010;90:1013-1062
©2010 by American Physiological Society
➡️ stimulation
➡️ inhibition
➡️ transformation
POTS:
autoimmune disease?
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
How to detect autoantibodies directed to GPCRs?
Serum/Ig from POTS/controls
Available detection methods
ELISA
Protein/receptor only
(Aab presence yes/not)
Cell-based assays
Functional receptor
(activation/inhibition)
Biological models
(living cells)
Whole biological target
system (cardiomyocytes)
Hall J et al Circulation (2022);146:613–622
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
How to detect autoantibodies directed to GPCRs?
Serum/Ig from POTS/controls
Available detection methods
ELISA
Protein/receptor only
(Aab presence yes/not)
Cell-based assays
Functional receptor
(activation/inhibition)
Biological models
(living cells)
Whole biological target
system (cardiomyocytes)
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Fedorowski et al. Europace 2017;19(7):1211-1219
Detection of antiadrenergic
activating autoantibodies
in POTS plasma
using CHO-K1 cells
Significant GPCR activation
blocked by specific antagonist
Non-
pharmacological
POTS treatment
Stop exacarbating medicines (blood
volume ⬇️; heart rate ⬆️ )
Increase water/fluid intake up to 2-3
l/daily
Increase salt intake/ smaller food
portions
Lower body compression garments (20-40
mmHg)
Beta blockers
Ivabradine
CCBs
Midodrine
Droxidopa
Pseudoephedrine
Fludrocortisone
Pirydostygmine
GI Symptoms
Muscle fatigue
Dexamphetamine
“Brain fog”
What drugs for POTS?
Fedorowski A. JIM 2019;285(4):352-66.
Raj S, Fedorowski A, Sheldon RS. CMAJ 2022;194(10):E378-E385.
Heart rate
Blood pressure
Summary
 Between 10 and 15% of COVID-19 convalescents develop Long COVID. One third of highly-
symptomatic patients have POTS and other forms of CV dysautonomia.
 CV autonomic dysfunction in Long COVID affects global (sinus tachycardia, hyper- and hypotensive
tendency) and local circulation (chest pain, migraine, oedema) with a wide spectrum of non-specific
symptoms such as fatigue and dyspnoea.
 Tilt testing/ active standing test, prolonged (Holter) ECG monitoring, and 24-h ABPM are useful in
diagnosis and therapy. Additional autonomic tests (deep breathing, Valsalva) may be useful but are not
necessary for treatment.
 Non-pharmacological measures (fluids and salt, tailored training, lifestyle changes, compression
garments, counterpressure manoeuvres) and heart-rate regulating plus blood pressure stabilizing drugs
are the cornerstone of therapy. Causal therapy is still waiting round the corner …
38
ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Thank you for your attention!
artur.fedorowski@ki.se
@ArturFedorowski

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Cardiovascular Autonomic Dysfunction in the Post-COVID Landscape: Detection and Management

  • 1. Cardiovascular Autonomic Dysfunction in the Post-COVID Landscape: Detection and Management Senior Consultant & Associate Professor Syncope and Dysautonomia Unit Karolinska University Hospital Artur Fedorowski, MD, PhD
  • 2. Cardiovascular Autonomic Dysfunction in the Post- COVID Landscape: Detection and Management Feb 23, 2023 Artur Fedorowski MD, PhD, Assoc. Prof., FESC Dept. of Cardiology, Karolinska University Hospital, Stockholm, Sweden
  • 3. How did it all begin?
  • 4. Unexplained post- COVID symptoms • Active and healthy 41-year-old woman (mild asthma only), married, two children, a team leader in an educational institution. • She fell ill with suspected COVID-19 infection in March 2020 and developed chronic fatigue, palpitations, orthostatic intolerance, problems with concentration and GI symptoms;
  • 5. Unexplained post- COVID symptoms • She was examined with CT thorax/abdomen (July -20), echocardiography (July -20), Holter ECG (August -20), spirometry with DLCO (Sep-20) and panel of laboratory tests with normal results except for slightly elevated average 24h heart rate of 89 bpm (66-153). Cardiac MRI normal. • Referred to the autonomic lab at university hospital in Malmö (S)
  • 6. Active standing test (beat-to-beat) 155 bpm Blood pressure Heart rate -40 mmHg Lightheadedness Standing
  • 8. Tilt testing 135 bpm Blood pressure Heart rate Lightheadedness Deep breathing test Blood pressure oscillations
  • 9. Interpretation of CV autonomic tests • Pathologic active standing test (sinus tachycardia = POTS; BP fall = initial orthostatic hypotension) • Pathologic Valsalva (hyperadrenergic response = frequently seen in POTS) • Pathologic tilt testing (sinus tachycardia max 143 bpm with symptom reproduction) = POTS dx confirmed (so called “hyperadrenergic type”) • Normal deep breathing response = normal parasympathetic control Johansson M et al. J Am Coll Cardiol Case Rep (2021); 3:573-580.
  • 10. Post Acute COVID Syndrome (PACS)/ Long COVID 1Post-acute COVID-19 is defined as persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of infection. 1 Nalbandian, A. et al. Nat Med 27, 601–615 (2021) 2 Ballering, A. et al. Lancet 400, 452-61 (2022) 3 Raman, B. et al. Eur Heart J 43, 1157-1172 (2022) 10-15% of COVID-19 patients develop chronic symptoms2 Major symptoms of PACS/Long COVID are now recognized as POTS3 Up to 30% of highly-symptomatic long COVID patients suffer from POTS and related CV dysautonomias3
  • 11. How big is the problem?
  • 12. 12 10-15% Young and Middle-aged Women overrepresented
  • 13. ”Long COVID is an often debilitating illness that occurs in at least 10% of severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) infections…At least 65 million individuals worldwide are estimated to have long COVID, with cases increasing daily …Long COVID encompasses multiple adverse outcomes, with common new-onset conditions including cardiovascular, thrombotic and cerebrovascular disease, type 2 diabetes, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and dysautonomia, especially postural orthostatic tachycardia syndrome (POTS)” Davis HE et al. Nat Rev Microbiol (2023); https://doi.org/10.1038/s41579-022-00846-2
  • 14. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Definition of dysautonomia/ autonomic dysfunction a disorder of the autonomic nervous system that causes disturbances in all or some autonomic functions and may result from the course of a disease (as diabetes) or from injury or poisoning Merriam-Webster Dictionary (merriam-webster.com)
  • 15. Typical manifestations of post-acute COVID- 19 syndrome-related cardiovascular autonomic dysfunction. POTS and inappropriate sinus tachycardia are the most prevalent phenotypes, found in ~30% of highly symptomatic patients. Global and local symptoms usually coexist. Wide spectrum of overlapping symptoms create a diagnostic dilemma for many doctors. Fedorowski, A., Sutton, R. Nat Rev Cardiol (2023)
  • 16. Canadian Journal of Cardiology DOI: (10.1016/j.cjca.2022.12.002) Hira R et al. Canadian Journal of Cardiology (2022) DOI: 10.1016/j.cjca.2022.12.002 POTS 21/70
  • 17. Canadian Journal of Cardiology DOI: (10.1016/j.cjca.2022.12.002) Hira R et al. Canadian Journal of Cardiology (2022) DOI: 10.1016/j.cjca.2022.12.002 POTS 21/70 Cardiovascular Autonomic Testing (CAT):  Active stand test (beat-to-beat)  Deep breathing test  Valsalva maneuvre  Quantitative sudomotor axon reflex testing o Tilt testing o Holter ECG o 24h-ambulatory BP monitoring
  • 18. Prevalence and clinical impact of Postural Orthostatic Tachycardia Syndrome in non-hospitalised patients with post-acute COVID-19 syndrome (PACS)  Non-hospitalised PACS-patients (n=365) recruited from the Long-COVID outpatient clinic at Karolinska University Hospital 2020-2022  117/365 diagnosed with POTS (32%) using active standing test or tilt testing  PACS + POTS had shorter walking distance in the 6-minute-walk-test (-92m, p<0.001)  PACS + POTS had lower self-assessed quality of life on the EuroQol-5D-Visual analogue scale (-9.8 points; p<0.001) Björnson M, Ståhlberg M, Fedorowski A, Bruchfeld J, et al. Manuscript in preparation.
  • 19. How to detect cardiovascular autonomic dysfunction in PACS?
  • 20. Mayuga K, Fedorowski A et al. Circulation: Arrhythmia and Electrophysiology. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. 2022; 15 (9): e007960, DOI: (10.1161/CIRCEP.121.007960) 20 Spahic JIM. 2023.Online. https://doi.org/10.1111/joim.13566
  • 21. ARTUR FEDOROWSKI, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Common POTS Symptoms 0 Cardiovascular  Palpitations  Lightheadedness  Chest discomfort/pain  Shortness of breath  Exercise intolerance 0 NeuroMuscular  Mental clouding (brain fog)  Headaches (migraine)  Sleep complaints  Involuntary movements Gastrointestinal Nausea and vomiting Constipation Weight loss Chronic Fatigue Visceral and regional pain Dysuria Multiple symptoms associated with orthostatic intolerance, fatigue and postural tachycardia Fedorowski A. JIM 2019;285(4):352-66.
  • 22. ARTUR FEDOROWSKI, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden How to understand and “measure” dysautonomic symptoms? Spahic J et al. J Intern Med (2023);293:91-99.  Although not always “visible”, the symptom burden is significant, often debilitating.  Cardiovascular and non-cardiovascular symptoms may be equally distributed.  Healthy controls differ from POTS patients in every symptom category.
  • 23. Mayuga K, Fedorowski A et al. Circulation: Arrhythmia and Electrophysiology. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. 2022; 15 (9): e007960, DOI: (10.1161/CIRCEP.121.007960) 23 Spahic JIM. 2023.Online. https://doi.org/10.1111/joim.13566
  • 24. www.escardio.org/guidelines Basic cardiovascular autonomic function tests  Active standing.  Valsalva manoeuvre & deep breathing.  Carotid sinus massage.  Tilt testing.  Ambulatory BP monitoring.  ECG monitoring Cardiovascular Autonomic Laboratory 2018 ESC Guidelines on Syncope – Michele Brignole & Angel Moya European Heart Journal (2018) 39, 1883–1948
  • 25. Active standing test Woman, 20 yo, EDS and POTS, unexplained syncope standing sitting supine Initial Orthostatic Hypotension SBP⇣ >40mmHg <30 sec
  • 26. Valsalva test Man, 37 yo, unexplained syncope START STOP sitting Pathologic reaction: No overshoot No HR reaction ANS damage
  • 27. Deep breathing test (1 min) Woman, 31 yo, POTS Normal respons Woman, 27 yo, POTS Pathologic response (no oscillations)
  • 28. Woman, 15 yo, orthostatic intolerance 1. Tilt testing for POTS/OH/VVS
  • 29. Woman, 52y; prolonged post-COVID symptoms “normal Holter ECG” POTS with inappropriate sinus tachycardia 106 bpm Heart rate ”spikes” and increased heart rate on average 2. Holter ECG for POTS/IST Ståhlberg M et al. The American journal of medicine. 2021;134(12):1451-6.
  • 30. Woman, 47y; post-COVID syndrome and syncope POTS with spontaneous hypotensive tendency 76 mmHg Unexpected BP drops that are easily interpreted as artefacts or erroneous BP measurements Rivasi et al. Eur Heart J 2022; https://doi.org/10.1093/eurheartj/ehac347. 3. 24h ABPM for POTS/OH/VVS  Low-BP phenotype  Hypotensive tendency  Disruption of circadian rhythm
  • 31. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Mahdi A et al Nov 5-7 2022 AHA Sessions Abstract Oral Presentation Endothelial and microvascular dysfunction in post-COVID POTS No MVD in cMRI in control group 4. In the pipeline …
  • 32. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Tissue responses to activation of specific adrenergic receptor subtypes Gerald W. Dorn II Physiol Rev 2010;90:1013-1062 ©2010 by American Physiological Society ➡️ stimulation ➡️ inhibition ➡️ transformation POTS: autoimmune disease?
  • 33. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden How to detect autoantibodies directed to GPCRs? Serum/Ig from POTS/controls Available detection methods ELISA Protein/receptor only (Aab presence yes/not) Cell-based assays Functional receptor (activation/inhibition) Biological models (living cells) Whole biological target system (cardiomyocytes) Hall J et al Circulation (2022);146:613–622
  • 34. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden How to detect autoantibodies directed to GPCRs? Serum/Ig from POTS/controls Available detection methods ELISA Protein/receptor only (Aab presence yes/not) Cell-based assays Functional receptor (activation/inhibition) Biological models (living cells) Whole biological target system (cardiomyocytes)
  • 35. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Fedorowski et al. Europace 2017;19(7):1211-1219 Detection of antiadrenergic activating autoantibodies in POTS plasma using CHO-K1 cells Significant GPCR activation blocked by specific antagonist
  • 36. Non- pharmacological POTS treatment Stop exacarbating medicines (blood volume ⬇️; heart rate ⬆️ ) Increase water/fluid intake up to 2-3 l/daily Increase salt intake/ smaller food portions Lower body compression garments (20-40 mmHg)
  • 37. Beta blockers Ivabradine CCBs Midodrine Droxidopa Pseudoephedrine Fludrocortisone Pirydostygmine GI Symptoms Muscle fatigue Dexamphetamine “Brain fog” What drugs for POTS? Fedorowski A. JIM 2019;285(4):352-66. Raj S, Fedorowski A, Sheldon RS. CMAJ 2022;194(10):E378-E385. Heart rate Blood pressure
  • 38. Summary  Between 10 and 15% of COVID-19 convalescents develop Long COVID. One third of highly- symptomatic patients have POTS and other forms of CV dysautonomia.  CV autonomic dysfunction in Long COVID affects global (sinus tachycardia, hyper- and hypotensive tendency) and local circulation (chest pain, migraine, oedema) with a wide spectrum of non-specific symptoms such as fatigue and dyspnoea.  Tilt testing/ active standing test, prolonged (Holter) ECG monitoring, and 24-h ABPM are useful in diagnosis and therapy. Additional autonomic tests (deep breathing, Valsalva) may be useful but are not necessary for treatment.  Non-pharmacological measures (fluids and salt, tailored training, lifestyle changes, compression garments, counterpressure manoeuvres) and heart-rate regulating plus blood pressure stabilizing drugs are the cornerstone of therapy. Causal therapy is still waiting round the corner … 38
  • 39. ARTUR FEDOROWSKI Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Thank you for your attention! artur.fedorowski@ki.se @ArturFedorowski

Editor's Notes

  1. Tissue responses to activation of specific adrenergic receptor subtypes. Open arrows depict endogenous signaling pathways. Clinically employed agonists are green arrows, and antagonists are red crosses.
  2. Fig. 1 The baroreceptor-mediated regulation of blood pressure. The afferent pathway transfers information from the arterial baroreceptors in carotid artery and aortic arch. The information reaches the vasomotor center in the medulla oblongata. The efferent pathway regulates two basic cardiovascular responses: heart rate and vascular tonus. Hypothalamus can activate vasopressin release as the additional regulatory mechanism. The higher brain functions can modulate the automatic cardiovascular responses.