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Post COVID Dysautonomias – Importance of Early Recognition

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Post COVID Dysautonomias

Post-COVID Dysautonomias:

The Importance of Early Recognition and Implementation of Recovery Programs

Brand new publication by Prof. Denise Hachul, Tatiana Almeida and Mauricio Scanavacca from Brazil, Instituto do Coração – HC-FMUSP and the Instituto Neuroheart – Diagnóstico e Tatamento das Disautonomias, São Paulo.

View original Article (in Portuguese only)

Publication extract summary*

The Brazilian Society of Cardiology recently published an excellent review paper by the expert team led by Prof. Denise Hachul from the Instituto do Coração at the University Hospital in São Paulo about autonomic dysfunction in post-COVID patients.

During the last three years, experts from all over the world have made it their task to better understand and treat the SARS-COV-2 infection and its unpredictable and sometimes chronic effects due to the increasing number of patients with persistent or intermittent multisystemic symptoms.

> Post-COVID syndrome

The post-COVID syndrome is described as a condition with various medical conditions that affect different body systems such as the cardiovascular, urogenital, gastrointestinal, endocrine, and nervous system and can have different degrees of severity. Characterized by persistent, unpredictable, multisystemic and psychofunctional symptoms, post-COVID syndrome significantly impacts the quality of life of many patients.

Studies are cited that show that many patients suffer from e.g., fatigue, insomnia, difficulty in concentrating, shortness of breath, headaches, joint and chest pains, even months after they have been discharged from the hospital. In addition, patients who required hospitalization or mechanical ventilation were found to have three times more mental health conditions, such as depression and anxiety, than those with mild or moderate disease. Post-COVID syndrome affects all age groups, but predominates in patients aged 30 to 50 who have had a mild acute infection.

Depression Long COVID
> Autonomic Dysfunctions affect quality of life

The authors quote studies describing the effects of the virus on the central nervous system, affecting the pain, mood, general coordination, and autonomic reflex circuits. The reason is that the virus alters the propagation speed of electrical impulses from neural synapses. Also, the autonomic nervous system can be affected, with the increased release of catecholamines causing psychocognitive and autonomic changes and resulting in symptoms such as tachycardia, shortness of breath, orthostatic intolerance, and syncope.

Dysautonomias such as postural orthostatic tachycardia syndrome (POTS), which is very common in post-COVID syndrome, is characterized by symptoms of orthostatic intolerance (without significant hypotension) and is associated with a sustained increase in sinus heart rate of at least 30 beats per minute when the patient stands upright for more than 30 seconds.

These potentially dysfunctional conditions cause a significant reduction in quality of life, social limitations, the impossibility to engage in physical activity and feed a vicious circle generating increasing functional disability. In turn, insecurity and thus secondary mental disorders are triggered.

> Early detection and diagnosis tools

Early detection of post-COVID syndrome is therefore fundamental as symptoms can last for months. It is important that persons who have been exposed to the virus or who present with one or more symptoms after administration of the vaccine undergo a complete physical, cardiovascular, respiratory, and neurological examination, even if they were oligo or asymptomatic.

The tilt table test is a proven method for diagnosing neurogenic and cardiovascular dysautonomia. For this purpose, an extended protocol for the “Autonomic Assessment” is recommended in order to identify the mechanisms of orthostatic intolerance in the patient.

* Sample picture

A monitoring system to continuously measure hemodynamic signals with dedicated software to capture and analyze full autonomic function is ideal here. Additionally, transcranial Doppler can be used to detect changes in microvascular resistance and dynamic obstructions to blood flow.

> Multidisciplinary approach and recovery programs required

Early diagnosis of post-COVID syndrome should be performed by a multidisciplinary team experienced in diagnostic methods and management of chronic patients. These patients have complex conditions and require integrative care, however, specialized care services with experience in this area are still rare, resulting in long delays in diagnosis and treatment.

The international cardiological communities are now challenged to address this important issue and implement specialized recovery programs to halt the progression of the disease, or at least alleviate patient discomfort.

*translated and summarized from Portuguese original article


Hachul, D. et al, Disautonomias Pós-COVID: Importância do Reconhecimento Precoce e da Implementação de Programas de Recuperação (2023), Arq Bras Cardiol. 2023; 120(3):e20230110; DOI:

View original Article (in Portuguese only)

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