COVID-19 Archives - Page 3 of 5 - Dr. Nicholas L. DePace, M.D., F.A.C.C.

Jun 19 0

Defining Long COVID

Posted by joeobiso

By Dr. Nicholas DePace and Dr. Joseph Columbo

Long‑COVID Definition

What exactly is Long-COVID syndrome?

Long-COVID or post-COVID-19 is an umbrella term that refers to symptoms persisting past the initial phase. There are many definitions that have been offered.

Official Definition of Long-COVID

Long-COVID has recently been defined as “the condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis”

Likewise, there now exists an International Classification of Diseases, Tenth Revision (ICD-10) code corresponding to Long-COVID condition—U09.9. Basically, there are individuals who do not completely recover over a period of weeks, usually 2–3 weeks. Since COVID-19 is a novel disease, there is still no consensus of the definition of Long-COVID symptoms.

Prevalence and Symptom Categories

Systematic Review Findings

A systematic review documented 20% of the reports of long-term COVID symptoms involved abnormal lung function, 24% involved neurological complaints and olfactory dysfunction, and 55% on specific widespread symptoms, mainly chronic fatigue and pain.

WHO’s Clinical Case Definition

The World Health Organization (WHO) developed a clinical case definition of Long-COVID by Delphi methodology that included 12 domains. However, the understanding of this definition has been going through changes as new evidence emerges, and we are gaining a better understanding of the consequences of COVID-19 and its mutations.

Symptom Duration and Impact

Usually, three or more months past the acute COVID-19 infection, symptoms that last for at least 2 months and cannot be explained by alternate diagnoses may ft this definition. These symptoms include fatigue, shortness of breath, cognitive dysfunction, and symptoms that affect the functional capacity of patients with daily living and productivity. Symptoms may fluctuate, fare up, or relapse over time, adversely affecting multiple organ systems.

P&S Nervous Systems Dysfunction in Long Covid

Role of P&S Nervous Systems

We propose that the delay between surviving the acute COVID infection and the onset of the Long-COVID symptoms is a function of the P&S nervous systems.

The P&S nervous systems function together to coordinate and control organs and organ systems to maintain normal organ function, even when the two nervous systems are dysfunctional.

Dysfunction and Symptoms

Prolonged P&S dysfunction, once severe enough, then leads to poor organ control and then symptoms. This process may take up to 3 months, faster if there were prior comorbidities, including age.

This is the basis for our claims that Long-COVID is a combination of both parasympathetic dysfunction(s) and sympathetic dysfunction(s). In our experience, the prolonged severe immune responses to COVID-19 seems to cause prolonged excessive parasympathetic responses, leading to secondary, prolonged, excessive beta-adrenergic (sympathetic) responses which prolongs and exaggerates heart rate, blood pressure, histaminergic, inflammatory, pain, and anxiety responses.

Gastrointestinal and Other Symptoms

The parasympathetic excess may also lead to both upper and lower GI symptoms.

The oxidative stress of the acute COVID-19 infection also causes oxidative stress which often leads to alpha-adrenergic (sympathetic) dysfunction which leads to orthostatic dysfunction and poor coronary and cerebral perfusion and the perfusion of the anatomy in between causing many of the rest of the symptoms of Long-COVID. Long-COVID may directly affect the lungs, heart, nervous system, kidneys, and pancreas.

Challenges in Research and Treatment

Lack of Standardized Definition

Unfortunately, the lack of a standardized definition for Long-COVID syndrome presents obstacles for researchers Fig. 1 The cytokine storm involved in COVID-19 infections is a source of oxidative stress.

Viruses and traumas (mental or physical) in general may lead to oxidative stress, which may lead to parasympathetic or sympathetic dysfunction(s), known as dysautonomia (adapted from Rasa et al.) ◂ Current Cardiology Reports 1 3 in studying the condition with controlled studies and arriving at a precise diagnosis and treatment algorithms. In addition, many patients with Long-COVID syndrome require rehospitalization especially those with comorbidities, such as cardiovascular disease, diabetes mellitus, obesity, cancer, and kidney disease.

This Post is an excerpt from Current Cardiology Reports: https://link.springer.com/article/10.1007/s11886-022-01786-2

Oct 07 0

Long-COVID Syndrome and the Cardiovascular System: A Review of Neurocardiologic Effects on Multiple Systems

Posted by joeobiso

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Dr. DePace, MD, FACC

Dr. Joseph Columbo

Note: This is an article recently published by Springer in their “Current Cardiology Reports” on their website. The Abstract is printed here. The entire article is availalbe by clicking this link or downloading it as a PDF

Abstract

Purpose of Review

Long-COVID syndrome is a multi-organ disorder that persists beyond 12 weeks post-acute SARS-CoV-2 infection (COVID-19). Here, we provide a definition for this syndrome and discuss neuro-cardiology involvement due to the effects of (1) angiotensin-converting enzyme 2 receptors (the entry points for the virus), (2) inflammation, and (3) oxidative stress (the resultant effects of the virus).

Recent Findings

These effects may produce a spectrum of cardio-neuro effects (e.g., myocardial injury, primary arrhythmia, and cardiac symptoms due to autonomic dysfunction) which may affect all systems of the body. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. Together with a full noninvasive cardiac workup, a full assessment of the autonomic nervous system, specifying parasympathetic and sympathetic (P&S) activity, both at rest and in response to challenges, is recommended. Cardiac symptoms must be treated directly. Cardiac treatment is often facilitated by treating the P&S dysfunction. Cardiac symptoms of dyspnea, chest pain, and palpitations, for example, need to be assessed objectively to differentiate cardiac from neural (autonomic) etiology.

Summary

Long-term myocardial injury commonly involves P&S dysfunction. P&S assessment usually connects symptoms of Long-COVID to the documented autonomic dysfunction(s).

Mar 10 0

Long COVID Syndrome

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LONG-COVID SYNDROME

for patients

NL DePace, MD, FACC and J Colombo, PhD, DNS, DHS

INTRODUCTION

COVID-19 is a major pandemic that is worldwide and may cause significant symptoms and possibly hospitalization. About 80% have mild to moderate disease. However, among the 20% with severe disease, 5% develop a critical illness. There is a subset of patients, however, who will have lingering, persistent or prolonged symptoms for weeks or month afterwards, which we termed “Long COVID.” (It does have many other names.) This has extended the significant worldwide morbidity from this pandemic. It is estimated that about 10% of patients who tested positive for COVID-19 will remain ill beyond three weeks and a smaller proportion for months. This is a subset that constitutes the Long-COVID syndrome. Globally, there are estimated over 200 million confirmed cases of COVID-19. Although the majority of infected individuals recover, we still do not know the exact percentage that will continue to experience symptoms or complications after the acute phase of the illness is over.

While it is estimated that 10% will develop a chronic syndrome, or symptoms that are persistent, this statistic may actually increase. Since this is a new illness, we do not know the cause or characteristics of the long-term sequelae of someone who has recovered from acute COVID,. Not just the quality of life, including mental health, but the employment and productivity issues become paramount. In our experience, approximately 20% of people will exhibit symptoms for more than five weeks and 10% will have symptoms for more than 12 weeks.

DEFINING LONG-COVID

The acute phase of COVID-19 infected patients has been well described and may a have varying number of symptoms and intensity. The recovery from COVID-19 usually occurs at seven to ten days after the onset of symptoms in mild disease, but could take up to six weeks in severe or critical illness. However, it is believed that even when one is ill for 3-6 weeks, they are probably not actively contagious. Again, symptoms beyond 12 weeks is considered Long-COVID Syndrome.

What exactly is Long-COVID Syndrome? There are many definitions that have been offered. Basically, there are individuals who do not completely recover over a period of weeks. Since COVID-19 is a novel disease, there is still no consensus of the definition of Long-COVID-19 symptoms. One study [1] found that 20% of the reports of long-term COVID symptoms involved abnormal lung function, 24% involved neurological complaints and olfactory dysfunction, and 55% on specific widespread symptoms, mainly chronic fatigue and pain. Usually, three or more months past the acute COVID-19 infection, symptoms that last for at least two months and cannot be explained by alternate diagnoses, may fit this definition. These symptoms include fatigue, shortness of breath, cognitive dysfunction, and symptoms that affect the functional capacity of individuals with daily living. Symptoms may fluctuate, flare up or relapse over time. Long-COVID-19 may adversely affect multiple organ systems, which include the kidneys, lungs, pancreas and heart.

Many patients with Long Covid Syndrome require rehospitalization especially those with comorbidities, such as cardiovascular disease, Diabetes Mellitus, obesity, cancer and kidney disease. Fatigue and muscle weakness are by far the major symptoms followed by dyspnea and then pain and discomfort. Then there is anxiety and depression and impaired concentration. Insomnia and sleep disorders present with lower frequency. Chronic cough may persist and arthralgias and myalgias may be present. Chest pain, cognitive impairment, dizziness and headache are also symptoms but less common than the ones above. Persistent sore throat, palpitations, lack of smell, diarrhea, vomiting, fever, blurry vision, lack of taste, nasal congestion, anorexia, nausea, ringing in the ears and rash may be present but at a much lower prevalence.

Autonomic dysfunction, which is an imbalance between the Parasympathetic and Sympathetic nervous systems, seems prevalent in Long-COVID-Syndrome. Autonomic dysfunction may explain multiple system symptoms, including some or all of: depression, chills, weakness, diarrhea, musculoskeletal, palpitations, tachycardia, dryness, cognitive dysfunction, headache, dizziness, visual effects, and tinnitus. Mechanisms of Long COVID Syndrome, like chronic inflammation, autoimmune, or hormonal imbalance, may be perpetuated by autonomic dysfunction. Lingering Autonomic Dysfunction also presents with auto-immune-like symptoms.

It has been postulated that there are two stages of Long-COVID-Syndrome: 1) symptoms that extend beyond three weeks, but less than 12 weeks, which is more of a subacute phase; and 2) chronic COVID symptoms that extend beyond 12 months. An interesting diagram and timeline has been postulated [2], which shows that Short-COVID will generally last less than three weeks from onset of symptoms. Post-acute COVID, or subacute COVID will last from onset of symptoms approximately up to 10-12 weeks and chronic COVID will last from onset of symptoms beyond 12 weeks. See Figure 1. It would make sense to group the Post-Acute or Subacute COVID, which lasts from up to 10-12 weeks, and then chronic COVID, which lasts more than 12 weeks as Long COVID Syndromes. Here we are more concerned with those symptoms that last more than 12 weeks, the true long- or prolonged-COVID Syndrome.

Figure 1: Classification of long COVID. [27]

Sometimes individuals are fairly asymptomatic during the viral infection phase of COVID, and by the time they develop Long-COVID symptoms, we do not know when the initial infection occurred nor are we certain (no positive tests). When these individuals develop multiple symptoms consistent with a Long-COVID Syndrome, we oftentimes consider them as probable, or possible Long COVID Syndrome. The problem is not only in those who have persistent symptoms who have never tested positive for COVID, but similarly in individuals who had upper respiratory tract infections and had a negative COVID test and then developed long prolonged symptoms. The question must be asked, “Did they have a false-negative test performed too early or too late in the disease course?” Antibodies are unreliable as up to 1/5 patients do not seroconvert, and antibody levels decrease over time and by three months oftentimes are not measurable. Not only is the symptom-load important with Long-COVID-Syndrome, but the economic cost to society, as 1/3 people in one survey did not return to their job for up to three weeks after being COVID-positive. In addition, given the similarity between Long-COVID Syndrome and Autonomic Dysfunction, and the ability of psychosocial stress to trigger symptoms of Autonomic Dysfunction further blurs the distinction between Long-COVID and Autonomic Dysfunction.

MULTIPLE ORGAN SYSTEMS INVOLVED

Long-COVID-Syndrome involve hyperinflammatory and hypercoagulable states that affect all organ systems. It reflects a dysfunction of the Angiotensin Converting Enzyme 2 (ACE 2) pathway. ACE-receptors are present in virtually every organ system. Workup consisting of pulmonary function tests, chest X-rays, six minute walk tests, pulmonary embolism workups (when needed), echocardiograms (even serially), and (at times) high resolution CT scans (to assess for fibrosis) should also be considered. These will be discussed under the Pulmonary section. Hematological assessment may lead to extending anti-coagulants against clots and high-risk survivors. A neuropsychiatric screening for anxiety, posttraumatic stress, sleep disorders, depression, cognitive impairment, memory abnormalities and other factors associated with brain fog is important. A neuropsychiatric screening should include a full autonomic dysfunction test, especially in patients with orthostatic intolerance symptoms and chronic fatigue syndromes. If there are renal function abnormalities, Nephrology follow-up and creatinine clearance determination with urinalysis evaluation may be needed. These may be performed in person or on virtual clinical visits. Next is a discussion of some of the various organ systems and how they are affected.

I. PULMONARY SYSTEM:

The pulmonary system, including the lungs, is the most commonly involved. Up to six months after hospitalization, pulmonary function abnormalities or structural changes may occur. Chronic complications, such as chronic cough, fibrotic lung changes also known as Long-COVID fibrosis or post-ARDS fibrosis, bronchiectasis and pulmonary vascular disease may occur [3] . Even if a person is asymptomatic, they may have CT scan abnormalities that are seen many months after infection has resolved. Approximately half of the patients with Long-COVID demonstrate chronic dyspnea. If COVID-19 leads to pulmonary fibrosis it may result in shortness of breath and the need for supplemental oxygen. There are also long-term risks of pulmonary embolisms and chronic pulmonary hypertension. Abnormal airway function may occur up to 11 months in severe COVID-19 infections [4]. Other abnormalities include abnormalities in total lung capacity, poor expiratory Vol at 1 second (FEV1), forced vital capacity (FVC), FEV1 to FVC ratio, and small airway function abnormalities [5]. Mild cases usually have persistent chronic cough, which may be due to fibrosis, bronchiectasis and pulmonary vascular disease.

II: CARDIAC INVOLVEMENT:

Common cardiac problems may include labile heart rate and blood pressure and myocarditis and pericarditis. Many individuals have palpitations. Reports of arrhythmia are not significant. The treat of blood clots, including venous and arterial thrombotic disease and pulmonary embolism, is significant [6]. These structural abnormalities may manifest itself in Long-COVID Syndrome long after recovery of acute illness and predispose to arrhythmias, breathlessness, and acute coronary events, such as heart attacks and chest pain syndromes.

Myocardial injury is the most common abnormality detected with acute COVID infection. It is usually detected even when patients are asymptomatic with no cardiac symptoms with elevated cardiac troponin levels [7]. Further research is ongoing as to whether this myocardial injury pattern, even when subclinical, may lead to increased arrhythmias and heart failure in the long-term.

Echocardiographic studies have shown abnormalities with COVID, including right ventricular dysfunction 26.3%, left ventricular dysfunction 18.4%, diastolic dysfunction 13.2% and pericardial perfusion 7.2%. To what extent this is reversible in patients who go on to Long-COVID-Syndrome is not known [8]. In addition, sleep abnormalities and difficulties that reduce quality of life have been noted in Long-COVID-19 Syndrome patients. These may also adversely affect cardiac function, provoke arrhythmias, elevate blood pressure and exacerbate or cause hypertensive states. Chest pain and palpitations are status post-acute phase of COVID. Many of the chest pains and palpitations, which appear to be cardiology in etiology, are actually due to autonomic dysfunction, including the postural orthostatic tachycardia state. Therefore, the importance of not only doing cardiac imaging, ambulatory monitoring, stress testing, six-minute walk test, echocardiography and other noninvasive cardiac workup, but also autonomic testing, such as cardio-respiratory monitoring, HRV interval testing, beat-to-beat blood pressure with tilt testing and sudomotor testing may be useful in diagnosing autonomic nervous dysfunction.

Arrhythmias are noted Long-COVID but attention to the use of anti-arrhythmic drugs, Amiodarone for example, must be used carefully in patients who have fibrotic pulmonary changes after COVID-19 [9].

III: NEUROLOGICAL:

Encephalitis, seizures, and other conditions including prolonged brain fog may occur for several months after acute COVID infection [10]. Neuropsychiatric sequelae are often common and reported with many post-viral symptoms, such as chronic tiredness, myalgias, depressive symptoms, non-restorative sleep [11]. Migraine headaches, often refractory to treatment, and late-onset headaches have been presumed to be due to high cytokine levels. Loss of taste and smell may also persist for up to six months and longer on follow-up of patients. Brain fog, cognitive impairment, concentration, memory difficulties, receptive language, executive function abnormalities may also persist over a long period of time. This may be related to autonomic dysfunction and other factors [12],[13],[14]. Psychiatric manifestations are also common in COVID-19 survivors of more than one month. Approximately 15% have at least some evidence of depression and post-traumatic stress, anxiety, insomnia and obsessive compulsive behavior [15]. Again, Long-COVID often involves brain fog. This may involve mechanisms of cardiac deconditioning, post-traumatic stress or dysautonomia. Long-term cognitive defects may be seen occurring in up to 20%-40% of patients [16],[17],[18]. The association between Long-COVID-Syndrome and brain fog may be the result of the autonomic dysfunction, specifically Sympathetic Withdraw [19], and the associated decreased cerebral perfusion [19, 20]. It is postulated that high catecholamine levels may lead to paradoxical vasal dilatation and increased activation of the Vagus nerve that may result even in syncope and also sympathetic activity withdraw [21].

Autonomic dysfunction has been noted to be significant. Patients with orthostatic tachycardia and inappropriate sinus tachycardia may benefit from heart rate management including beta-blockers [22] and other autonomic therapies [personal observations]. The most frequent neurological long-term symptoms in patients were myalgias, arthralgias, sleeping troubles and headaches [23].

Muscle wasting and fragility are often seen prolonged. This is because COVID-19 when it is severe may cause catabolic muscle weakness and feeding difficulties [24]. Symptoms consistent with orthostatic hypotension syndrome and painful small fiber neuropathy were reported in as short as three weeks and as long as three months [25, 26, 27].

Treatment of autonomic nervous systems disorders involves exercise with both aerobic and resistant elements in a graded fashion that oftentimes begin with recumbent exercises, “low and slow” [28]. Fluid and electrolyte repletion is required. Avoiding exacerbating factors, such as prolonged sitting and warm environments is recommended. Some counter maneuvers and isometric exercises, compression garments especially up to the waist, or abdominal binders are recommended. Pharmacological treatment that may involve many different regimens may be prescribed, such as volume expanders (e.g., Fludrocortisone or Desmopressin) may be used along with vasoactivation (e.g., Midodrine or Mestinon). If there are prominent hyperadrenergic symptoms, Propranolol, Clonidine, Methyldopa or other beta-blockers may be considered, especially for a postural orthostatic tachycardia response.

Autonomic dysfunction involving gastrointestinal, urinary, pupillomotor (e.g., light sensitivity) and erectile dysfunction were more represented than non-neurological symptom groups. Other prominent autonomic dysfunctions in these post-COVID individuals included secretomotor and sweating abnormalities in about half the study population and thermoregulatory alterations. Autonomic dysfunction has been reported in up to 63% of patients having survived a COVID-19 infection

Chronic fatigue syndrome or Myalgic Encephalomyelitis, also known as post-infective syndrome, has been commonly recognized in the Long-COVID Syndrome [29, 30, 31]. Fatigue at three weeks post symptoms may occur in 13-33% of patients. There are many factors responsible which include sleep disturbances, autonomic dysfunction with sympathetic predominance, endocrine disturbances, abnormalities of the hypothalamic-pituitary-adrenal axis, reactive mood disorders and depression and anxiety. Findings therefore concluded that chronic fatigue post Long-COVID Syndrome is multifactorial. In fact, in the cohort at our autonomic clinic we have found significant disturbances in Cardiorespiratory and HRV testing in patients with chronic fatigue with Long-COVID-Syndrome with abnormal autonomic responses, including sympathetic withdraw (associated with orthostatic dysfunction) and vagal excess with postural change (associated with pre-syncope symptoms). Both autonomic dysfunctions are associated with poor cerebral and possibly coronary perfusion. These symptoms present regardless of whether they have drops in blood pressure, postural rise in heart rate or none of the above changes.

It is initially believed that SARS-COVID-19 causes sympathetic nervous system activation with catecholamine excess of activation in a sympathetic storm which activates the renin angiotensin system. Simultaneously, there is inhibition of the parasympathetic nervous system mediated anti-inflammatory effect, that leads to a decrease in neuro-vagal anti-inflammatory response and enhances the cytokine storm. This all leads to cardiopulmonary complications and COVID-19-induced dysautonomia [32]. The Parasympathetic responses reported above are found at rest. There is an abnormal Parasympathetic response to stress that may also occur [33], exaggerating the dynamic Sympathetic response to stress, thereby amplifying and prolonging the Sympathetically-mediated inflammatory, histaminergic, pain, and anxiety responses in a post-traumatic-like fashion.

IV. GASTROINTESTINAL SYMPTOMS ASSOCIATED WITH LONG-COVID SYNDROME.

At least 76% of patients had one of the GI sequelae symptoms 90-days after discharge of COVID-19, persisting to six months after disease onset [34]. COVID-19 may cause intestinal dysfunction due to changes in intestinal microbes and an increase in inflammatory cytokine, as well as Parasympathetic dysfunction. In the chronic phase the Gastrointestinal (GI) sequelae may include persistent anorexia, vomiting, abdominal pain along with diarrhea. GI upset may also be due to gastric and intestinal motility dysfunction due to COVID-induced Parasympathetic dysfunction. For example, diarrhea and abdominal pain may be due to excessive Parasympathetic activity causing overly-rapid GI motility.

Studies are currently evaluating the long-term consequences of COVID-19 on the GI system, including postinfectious, Irritable Bowel Syndrome, and Dyspepsia.

V. HEMATOLOGICAL SEQUELAE OF LONG-COVID SYNDROME.

Late onset hematological complications with Long-COVID-19 has become an emerging medical problem for the hematologists. These include coagulopathy disorders, immune-thrombotic states, and hemorrhagic events. Long-COVID venous thromboembolism has been estimated to be less than 5% [35].

VI: KIDNEY DISEASE:

Patients that are extremely frail and have chronic comorbidities are at an increased risk for kidney disease and progression of kidney failure after infection of SARS-CoV-2.

VII: OLFACTORY and GUSTATORY ABNORMALITIES:

Recovery of the Olfactory and Gustatory system may last more than one month after the onset of smell and taste loss [36, 37]. Long-lasting effects on taste and smell are uncommon but have been noted in isolated cases.

PATHOPHYSIOLOGY OF LONG COVID-19:

The mechanism behind the causation of Long-COVID Syndrome may be multifactorial. Oxidative Stress, due to the viral infection, may affect all systems compounded by hyperinflammation (a typical immune response to virus) with altered autonomic function (a result of a strong viral infection) as measured by cardiorespiratory monitoring. Oxidative Stress decreases the efficiency of Mitochondria, the energy producer in all cells, initiating the cascade of symptoms associated with Long-COVID.

TREATMENT IN LONG-COVID SYNDROME:

For the most part, supportive therapy for Long-COVID symptoms is a keystone and there is treatment for autonomic dysfunction. As mentioned earlier, volume expanders and vasodilators in addition to fluids, electrolytes, compression garments, and various exercise techniques have been prescribed for orthostatic intolerance symptoms. Omega-3 fatty acid and dietary supplementation may help resolve inflammatory imbalance [38]. L-arginine to boost Nitric Oxide production has been proposed [39]. Nitric Oxide maintains or improves the health and function of endothelial cells and benefits the immune system, especially in chronic fatigue states. Various antioxidants and zinc have been recommended to relieve Oxidative Stress. All of these therapies also effect proper autonomic function to help relieve Long-COVID symptoms [40]. Vaccination has been suggested as possibly a factor that may ease symptoms of Long-COVID. Most breakthrough infections were mild or asymptomatic, although persistent symptoms did occur. Mental health conditions may be treated with various psychological aides, such as cognitive behavioral therapy as well as antidepressants, including tricyclics.

LONG-COVID:

The symptoms of Long-COVID Syndrome may all be associated with autonomic dysfunction as measured with Cardio-Respiratory testing [40] and relieved with appropriate autonomic therapy based on the Cardio-Respiratory test [41].

REFERENCES

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[23] Salamanna F, Veronesi F, Martini L, Landini MP, Fini M. Post-COVID-19 Syndrome: The Persistent Symptoms at the Post-viral Stage of the Disease. A Systematic Review of the Current Data. Front Med (Lausanne). 2021 May 4;8:653516. doi: 10.3389/fmed.2021.653516. PMID: 34017846; PMCID: PMC8129035.

[24] Hosey MM, Needham DM. Survivorship after COVID-19 ICU stay. Nat Rev Dis Primers. 2020 Jul 15;6(1):60. doi: 10.1038/s41572-020-0201-1. PMID: 32669623; PMCID: PMC7362322.

[25] Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, Lim PB. Autonomic dysfunction in ‘long COVID’: rationale, physiology and management strategies. Clin Med (Lond). 2021 Jan;21(1):e63-e67. doi: 10.7861/clinmed.2020-0896. Epub 2020 Nov 26. PMID: 33243837; PMCID: PMC7850225.

[26] Hellmuth J, Barnett TA, Asken BM, Kelly JD, Torres L, Stephens ML, Greenhouse B, Martin JN, Chow FC, Deeks SG, Greene M, Miller BL, Annan W, Henrich TJ, Peluso MJ. Persistent COVID-19-associated neurocognitive symptoms in non-hospitalized patients. J Neurovirol. 2021 Feb;27(1):191-195. doi: 10.1007/s13365-021-00954-4. Epub 2021 Feb 2. PMID: 33528824; PMCID: PMC7852463.

[27] Novak E, Neurological Science, 2020.

[28] Fu Q, Vangundy TB, Shibata S, Auchus RJ, Williams GH, Levine BD. Exercise training versus propranolol in the treatment of the postural orthostatic tachycardia syndrome. Hypertension. 2011 Aug;58(2):167-75. doi: 10.1161/HYPERTENSIONAHA.111.172262. Epub 2011 Jun 20. PMID: 21690484; PMCID: PMC3142863.

[29] Townsend L, Dowds J, O’Brien K, et al.: Post–COVID-19 Respiratory Complications. Annals ATS;18(6), June 2021

[30] Poenaru S, Abdallah SJ, Corrales-Medina V, Cowan J. COVID-19 and post-infectious myalgic encephalomyelitis/chronic fatigue syndrome: a narrative review. Ther Adv Infect Dis. 2021 Apr 20;8:20499361211009385. doi: 10.1177/20499361211009385. PMID: 33959278; PMCID: PMC8060761.

[31] Sandler CX, Wyller VBB, Moss-Morris R, Buchwald D, Crawley E, Hautvast J, Katz BZ, Knoop H, Little P, Taylor R, Wensaas KA, Lloyd AR. Long COVID and Post-infective Fatigue Syndrome: A Review. Open Forum Infect Dis. 2021 Sep 9;8(10):ofab440. doi: 10.1093/ofid/ofab440. PMID: 34631916; PMCID: PMC8496765.

[32] Al-Kuraishy HM, Al-Gareeb AI, Qusti S, Alshammari EM, Gyebi GA, Batiha GE. Covid-19-Induced Dysautonomia: A Menace of Sympathetic Storm. ASN Neuro. 2021 Jan-Dec;13:17590914211057635. doi: 10.1177/17590914211057635. PMID: 34755562; PMCID: PMC8586167.

[33] Tobias H, Vinitsky A, Bulgarelli RJ, Ghosh-Dastidar S, Colombo J. Autonomic nervous system monitoring of patients with excess parasympathetic responses to sympathetic challenges – clinical observations. US Neurology. 2010; 5(2): 62-66.

[34] Weng J, Li Y, Li J, Shen L, Zhu L, Liang Y, Lin X, Jiao N, Cheng S, Huang Y, Zou Y, Yan G, Zhu R, Lan P. Gastrointestinal sequelae 90 days after discharge for COVID-19. Lancet Gastroenterol Hepatol. 2021 May;6(5):344-346. doi: 10.1016/S2468-1253(21)00076-5. Epub 2021 Mar 10. PMID: 33711290; PMCID: PMC7943402.

[35] Patell R, Bogue T, Koshy A, Bindal P, Merrill M, Aird WC, Bauer KA, Zwicker JI. Postdischarge thrombosis and hemorrhage in patients with COVID-19. Blood. 2020 Sep 10;136(11):1342-1346. doi: 10.1182/blood.2020007938. PMID: 32766883; PMCID: PMC7483433.

[36] Addison AB, Wong B, Ahmed T, Macchi A, Konstantinidis I, Huart C, Frasnelli J, Fjaeldstad AW, Ramakrishnan VR, Rombaux P, Whitcroft KL, Holbrook EH, Poletti SC, Hsieh JW, Landis BN, Boardman J, Welge-Lüssen A, Maru D, Hummel T, Philpott CM. Clinical Olfactory Working Group consensus statement on the treatment of postinfectious olfactory dysfunction. J Allergy Clin Immunol. 2021 May;147(5):1704-1719. doi: 10.1016/j.jaci.2020.12.641. Epub 2021 Jan 13. PMID: 33453291.

[37] Le Bon SD, Pisarski N, Verbeke J, Prunier L, Cavelier G, Thill MP, Rodriguez A, Dequanter D, Lechien JR, Le Bon O, Hummel T, Horoi M. Psychophysical evaluation of chemosensory functions 5 weeks after olfactory loss due to COVID-19: a prospective cohort study on 72 patients. Eur Arch Otorhinolaryngol. 2021 Jan;278(1):101-108. doi: 10.1007/s00405-020-06267-2. Epub 2020 Aug 4. PMID: 32754871; PMCID: PMC7402072.

[38] Weill P, Plissonneau C, Legrand P, Rioux V, Thibault R. May omega-3 fatty acid dietary supplementation help reduce severe complications in Covid-19 patients? Biochimie. 2020 Dec;179:275-280. doi: 10.1016/j.biochi.2020.09.003. Epub 2020 Sep 10. PMID: 32920170; PMCID: PMC7481803.

[39] Adebayo A, Varzideh F, Wilson S, Gambardella J, Eacobacci M, Jankauskas SS, Donkor K, Kansakar U, Trimarco V, Mone P, Lombardi A, Santulli G. l-Arginine and COVID-19: An Update. Nutrients. 2021 Nov 5;13(11):3951. doi: 10.3390/nu13113951. PMID: 34836206; PMCID: PMC8619186.

[40] Colombo J, Weintraub MI, Munoz R, Verma A, Ahmed G, Kaczmarski K, Santos L, and DePace NL Long-COVID and the Autonomic Nervous System: The journey from Dysautonomia to Therapeutic Neuro-Modulation, Analysis of 152 Patient Retrospectives. Submitted, 2022.

[41] DePace NL, Colombo J. Autonomic and Mitochondrial Dysfunction in Clinical Diseases: Diagnostic, Prevention, and Therapy. Springer Science + Business Media, New York, NY, 2019.

Jun 29 0

Coronavirus Induces Oxidative Stress Leading to Autonomic Dysfunction – Part 5

Posted by joeobiso

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Click here to download the full 5 Part Article

Notes: This is the fifth in a series of 5 blog posts about COVID-19 and Autonomic Dysfunction. This a pre-publication release that will be featured in a major medical journal.

Coronavirus Induces Oxidative Stress Leading to Autonomic Dysfunction Often With Delayed Symptom Onset

Heather L. Bloom, MD¹ and Joseph Colombo, PhD, DNM, DHS²

Electrophysiology, Atlanta Veterans Affairs Medical Center and Emory University Medical School, Atlanta, GA bloom@gmail.com
Parasympathetic & Sympathetic Nervous System Consultant, Franklin Cardiovascular Associates, PA & Autonomic Dysfunction and POTS Center, Sewell, NJ, and Senior Medical Director & CTO, Physio PS, Inc., Atlanta, GA, dovetech@erols.com

Correspondence should be addressed to Dr. Colombo, dovetech@erols.com

CONCLUSIONS

In all, poor brain and cardiac perfusion is often the result of Oxidative Stress mediated P&S Dysfunction and if both are not treated they will augment and amplify each other and their resulting symptoms. Unfortunately, most of the therapies for P&S Dysfunction are off-label. Also, they are most effective at low doses. High doses cause side effects which lead to or are caused by additional P&S Dysfunctions which are induced by these high dose pharmaceuticals. Fortunately, Antioxidants are known to also help treat P&S Dysfunction as well as Oxidative Stress. Either way, P&S monitoring provides an objective, scientifically-based, outcomes-driven assessment of the individual patient’s responses to disease, disorder and therapy. This helps to titrate therapy specifically for the individual patient, using the individual as their own baseline. This also helps to identify medications that are not helping and perhaps may be harming the patient.

Relieving Oxidative Stress and the associated P&S Dysfunction helps to relieve lightheadedness and dizziness, fatigue, sleep difficulties, GI symptoms (upper or lower), Anxiety/Depression, difficult to control BP, blood glucose or hormone levels, headache or migraine, brain-fog, cognitive or memory difficulties, etc. In doing so, patients have improved quality of life and productivity, improved outcomes, reduced hospitalizations and re-hospitalizations, and thereby reduced healthcare costs. The additional information from P&S Monitoring with therapy individualized for the patient helps physicians go beyond merely managing the disorder, helping physicians to restore health and promote wellness as well.

DATA AVAILABILITY

Patient data are from patient records and files and are therefore HIPAA protected. Therefore, data availability is limited. You may contact the corresponding author to request access and limited access may be granted.

CONFLICTS OF INTEREST

Dr. Bloom has no conflicts of interest. Dr. Colombo is Senior Medical Director and Chief Technology Officer of Physio PS, Inc., the provider of the P&S Monitoring technology.

FUNDING

This project was not funded under any grant or contract.

REFERENCES

_________________

[1] Murray GL. COVID-19 cardiac complications: Is an easy, safe treatment strategy right under our noses? J Cardiovasc Dis Diag. 2020; 8:5. doi: 10.37421/jcdd.2020.8.415.

2 DePace NL, Colombo J. Autonomic and Mitochondrial Dysfunction in Clinical Diseases: Diagnostic, Prevention, and Therapy. Springer Science + Business Media, New York, NY, 2019.

3 Acosta C, DePace NL, DePace NL, Kaczmarski K, Pinales JM, and Colombo J. Antioxidants effect changes in systemic parasympathetic and sympathetic nervous system responses and improve outcomes. Cardio Open. 2020; 5(1): 26-36. doi: 10.33140/COA.05.01.04

⁴Colombo J, Arora RR, DePace NL, Vinik AI. Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and Outcomes. Springer Science + Business Media, New York, NY, 2014.

5 Vinik A, Ziegler D. Diabetic cardiovascular autonomic neuropathy. Circulation. 2007; 115: 387-397.

6 Vinik AI, Maser RE, Nakave AA. Diabetic cardiovascular autonomic nerve dysfunction. US Endocrine Disease. 2007; Dec: 2-9.

7 Malik, M. The Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability, standards of measurement, physiological interpretation, and clinical use. Circulation. 1996; 93:1043-1065.

⁸ Malik, M. and the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability, standards of measurement, physiological interpretation, and clinical use. European Heart Journal. 1996, 17: 354-381.

⁹ Akselrod S, Oz O, Greenberg M, Keselbrener L. Autonomic response to change of posture among normal and mild-hypertensive adults: investigation by time-dependent spectral analysis. J Auton Nerv Syst. 1997 May 12;64(1):33-43.

¹⁰ Piña IL, Di Palo KE, Ventura HO. Psychopharmacology and Cardiovascular Disease. JACC. 2018; 71(20): 2346-2359.

1¹ Arora RR, Bulgarelli RJ, Ghosh-Dastidar S, Colombo J. Autonomic mechanisms and therapeutic implications of postural diabetic cardiovascular abnormalities. J Diabetes Science and Technology. 2008; 2(4): 568-71.

12 DePace NL, Vinik AI, Acosta C and Colombo J. Oral vasoactive medications: A Review of Midodrine, Droxidopa, and Pseudoephedrine as Applied to Orthostatic Dysfunction. NEJM. 2020. Submitted.

¹³ Vinik AI, Bloom HL, Colombo J. Differential effects of adrenergic antagonists (carvedilol vs. metoprolol) on parasympathetic and sympathetic activity: A comparison of measures. Heart International. Heart Int. 2014; 9(1): 7-14; DOI: 10.5301/HEART.2014.12495.

¹⁴ Bloom HL, Vinik AI, Colombo J. Differential effects of adrenergic antagonists (carvedilol vs. metoprolol) on parasympathetic and sympathetic activity: A comparison of clinical results. Heart Int. 2014 ; 9 (1): 15-21; DOI: 10.5301/HEART.2014.12496.

¹⁵ Murray GL and Colombo J. (R)Alpha Lipoic Acid is a Safe, Effective Pharmacologic Therapy of Chronic Orthostatic Hypotension Associated with Low Sympathetic Tone. Int J Angiol. In Print, 2018.

KEY WORDS

Coronavirus, Parasympathetic, Sympathetic, Oxidative Stress, Antioxidants

ABBREVIATIONS

ALA Alpha-Lipoic Acid

ANS Autonomic Nervous System

CoQ10 Co-enzyme Q10

COVID-19 Coronavirus (SARS-CoV-2)

P&S Parasympathetic and Sympathetic

PE Parasympathetic Excess

POTS Postural Orthostatic Tachycardia Syndrome

SE Sympathetic Excess

SW Sympathetic Withdrawal

[i] Colombo J, Arora RR, DePace NL, Vinik AI. Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and Outcomes. Springer Science + Business Media, New York, NY, 2014.

[ii] Vinik A, Ziegler D. Diabetic cardiovascular autonomic neuropathy. Circulation. 2007; 115: 387-397.

[iii] Vinik AI, Maser RE, Nakave AA. Diabetic cardiovascular autonomic nerve dysfunction. US Endocrine Disease. 2007; Dec: 2-9.

[iv] Malik, M. The Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability, standards of measurement, physiological interpretation, and clinical use. Circulation. 1996; 93:1043-1065.

[v] Malik, M. and the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability, standards of measurement, physiological interpretation, and clinical use. European Heart Journal. 1996, 17: 354-381.

[vi] Akselrod S, Oz O, Greenberg M, Keselbrener L. Autonomic response to change of posture among normal and mild-hypertensive adults: investigation by time-dependent spectral analysis. J Auton Nerv Syst. 1997 May 12;64(1):33-43.

Jun 15 1

Coronavirus Induces Oxidative Stress Leading to Autonomic Dysfunction – Part 4

Posted by joeobiso

Click here to download this post

Notes: This is the fourth in a series of 5 blog posts about COVID-19 and Autonomic Dysfunction. This a pre-publication release that will be featured in a major medical journal.

Coronavirus Induces Oxidative Stress Leading to Autonomic Dysfunction Often With Delayed Symptom Onset

Heather L. Bloom, MD¹ and Joseph Colombo, PhD, DNM, DHS²

Electrophysiology, Atlanta Veterans Affairs Medical Center and Emory University Medical School, Atlanta, GA bloom@gmail.com
Parasympathetic & Sympathetic Nervous System Consultant, Franklin Cardiovascular Associates, PA & Autonomic Dysfunction and POTS Center, Sewell, NJ, and Senior Medical Director & CTO, Physio PS, Inc., Atlanta, GA, dovetech@erols.com

Correspondence should be addressed to Dr. Colombo, dovetech@erols.com

THERAPY OPTIONS

In general, Oxidative Stress is treated with Antioxidants; more on this below in the Non-Pharmaceutical section. Non-pharmaceutical therapy is often the primary P&S therapy which may often be accelerated with pharmaceutical therapy. Often, once P&S balance is re-established, assuming no end-organ dysfunction, the P&S will carry forward independent of pharmaceutical therapy and only non-pharmaceutical, maintenance therapy may be required. This is typically in the form of Antioxidants to help maintain proper Antioxidant levels in the body. With chronic disease or disorder, as with aging, antioxidants are depleted in the body and production is slowed; therefore, supplemental therapy is needed.

Pharmaceutical Therapy Options

Pharmaceutical therapy options are recommended based on patient history [[i]]. In general they included the following. For SW, 2.5 mg Midodrine titrated slowly, as needed, from qd to tid. For Orthostatic Hypotension, including pre-clinical cases, the first dose is recommended around dinner, four hours before laying down, when BP tended to be lowest. For POTS patients, morning doses are recommended since symptoms are typically more significant at that time. Midodrine is contraindicated for patients with supine hypertension and for patients with resting BPs higher than 160/90 mmHg [[ii]]. Some patients do not respond to, or are contra-indicated for, Midodrine. While Northera is the recommended alternate, it is very expensive and 30 to 60 mg Mestinon, qd, is recommended as the first alternate. Only if patients are unresponsive to Mestinon is Northera considered, but still must be approved. Non-pharmaceutical alternates are discussed below. Low dose Fludrocortisone or Pseudoephedrine may be suitable adjunctives [[iii]].

Note, if patients present with SW and high BP, the high BP is (at least in part) compensatory for the associated Orthostatic Hypotension. In these cases treating the Hypertension as the primary typically confounds the condition and may even cause BP to increase, as the poor brain perfusion is exacerbated and the body defeats the therapy. In most cases, relieving SW organically reduces BP [11] and any remaining Hypertension may then be treated as the primary, once the patient’s P&S nervous systems stabilize.

For PE low-dose anti-cholinergic therapy (very low dose antidepressant therapy) is recommended. For example, no more than 10.0 mg, qd, dinner Nortriptyline (primary) or 20mg, qd, Duloxetine (secondary) is recommended. Clinical doses of these pharmaceuticals will exacerbate the condition with additional symptoms. Often patients that present with long standing PE, who have been referred for Psych-eval and have been prescribed much higher doses of these pharmaceuticals, or have been prescribed antidepressants for more than six months with little or no relief, no longer respond or tolerate the recommended low-dose anti-cholinergic therapy, and alternate therapies are needed. The primary alternate anti-cholinergic therapy recommended is “Low-and-Slow” exercise (see below) and was also recommended to help re-condition the heart muscle for improved cardiac output and thereby improved brain perfusion. The recommended anti-cholinergic therapy tends to have little effect on BP and helps to pattern sleep. If a more potent anti-cholinergic is needed and weight-gain is not a problem, 10.0 mg, qd, dinner Amitriptyline is recommended.

If PE presents with SE and with established Hypertension or Cardiovascular Disease, then low-dose or dose equivalent Carvedilol is recommended. Carvedilol treats all three simultaneously. It is not only a beta-blocker, but it is also an antioxidant [[iv],[v]].

Note, PE often causes secondary SE. SE may lead to hypertension. In these cases, treating the Hypertension as the primary exacerbates the Hypertension, similar to SW. In most cases, relieving PE organically relieves SE (after a few months) which, in turn, organically reduces BP [2] and any remaining Hypertension may then be treated as the primary, once the patient’s P&S nervous systems stabilize.

For (stand) SE, therapy depends on the differential. If SE is demonstrated with PE indicating (pre-clinical) Vasovagal Syncope, then PE therapy is followed as the primary and typically the SE is relieved organically. If SE is demonstrated with a drop in HR from resting to stand indicating (pre-clinical) Neurogenic Syncope, volume building and often Midodrine helps to treat the stand SE. Any remaining SE indicates (by omission) possible Cardiogenic Syncope and more testing is required to diagnose and treat. [4]

Autonomically mediated arrhythmia, with or without SE may be documented. Autonomically mediated arrhythmia is associated with inefficient circulation and may be another result of Oxidative Stress. Autonomically mediated arrhythmia with SE may contribute to Cardiogenic syncope, and treating SE may help to relieve the arrhythmia. Autonomically mediated arrhythmia with PE may contribute to Vasovagal Syncope, and treating SE may help to relieve the arrhythmia. Autonomically mediated arrhythmia with normal Sympathovagal Balance (SB = S/P, a resting baseline measurement), the arrhythmia is not autonomic and further testing maybe required to diagnose and treat. [4]

Non-Pharmaceutical Therapy Options

In general, Psychosocial Stress reduction is recommended with history-specific Antioxidant and Nitric Oxide supplement recommendations to reduce Oxidative Stress and improve blood flow [4]. Nitric Oxide also has Antioxidant properties. Non-Pharmaceutical therapy options are recommended if patients are intolerant or unresponsive to the pharmaceutical options.

Alpha-Lipoic Acid (ALA) and Co-Enzyme Q10 (CoQ10) are two of the most potent Antioxidants made in the body. ALA tends to be more selective for nerves. CoQ10 tends to be more selective for cardiac tissue. Both help to recycle other Antioxidants, including Vitamins A, C & E, and Glutathione. Specifically for SW, 600 mg tid, Alpha-Lipoic Acid, titrated as needed and tolerated [[vi]], is recommended. Exercise is arguably the most potent Antioxidant available. For PE (which is an autonomic state that amplifies the stress response of all stressors including healthy stressors such as exercise), six months of “Low-and-Slow” exercise is recommended to retrain the nervous system to accept small, healthy stresses before more significant stresses may be tolerated. Low-and-Slow exercise is characterized by walking at no more than 2 mph for 40 contiguous minutes per day, for 6 months (suitable alternates include slow motion rowing, or slow motion bicycling or pedaling are options) [4]. Exercise that breaks down muscle or connective tissue or that raises HR and BP too fast should be strictly avoided. Often “Low-and-Slow” exercise is augmented, especially if the patient reported significant sleep difficulties, by 20 minutes of supine, 15° head-down posture around two hours before bed-time and up to three times per day, as needed, but in any instance, at least 2 hours after low-dose Midodrine dosing. Patients who are too lightheaded to sit up or too exercise intolerant may perform supine Low-and-Slow exercise by lying on the floor next to the bed with their lower legs on the bed, and only move their lower legs like they were walking at 2 mph, for the prescribed 40 minutes (see insert).

[i] Piña IL, Di Palo KE, Ventura HO. Psychopharmacology and Cardiovascular Disease. JACC. 2018; 71(20): 2346-2359.

[ii] Arora RR, Bulgarelli RJ, Ghosh-Dastidar S, Colombo J. Autonomic mechanisms and therapeutic implications of postural diabetic cardiovascular abnormalities. J Diabetes Science and Technology. 2008; 2(4): 568-71.

[iii] DePace NL, Vinik AI, Acosta C and Colombo J. Oral vasoactive medications: A Review of Midodrine, Droxidopa, and Pseudoephedrine as Applied to Orthostatic Dysfunction. NEJM. 2020. Submitted.

[iv] Vinik AI, Bloom HL, Colombo J. Differential effects of adrenergic antagonists (carvedilol vs. metoprolol) on parasympathetic and sympathetic activity: A comparison of measures. Heart International. Heart Int. 2014; 9(1): 7-14; DOI: 10.5301/HEART.2014.12495.

[v] Bloom HL, Vinik AI, Colombo J. Differential effects of adrenergic antagonists (carvedilol vs. metoprolol) on parasympathetic and sympathetic activity: A comparison of clinical results. Heart Int. 2014 ; 9 (1): 15-21; DOI: 10.5301/HEART.2014.12496.

[vi] Murray GL and Colombo J. (R)Alpha Lipoic Acid is a Safe, Effective Pharmacologic Therapy of Chronic Orthostatic Hypotension Associated with Low Sympathetic Tone. Int J Angiol. In Print, 2018.