Minimal Objective Autonomic Dysfunction in Long-COVID
Meredith Bryarly1, Juan Cabrera2, surendra barshikar2, Steven Vernino2
1Neurology, UT Southwestern, 2UT Southwestern Medical Center

Our aim was to characterize autonomic symptoms, severity and objective measures of autonomic function in patients with post-COVID syndrome.


Many patients report persistent symptoms that continue beyond the acute phase of COVID-19 (SARS-CoV-2) infection, variably called “long-COVID”, “post-COVID”, or “long-haul COVID”. Common symptoms include fatigue, orthostatic intolerance, cognitive impairment, and syncope, similar to the symptom profile of POTS.  Although highly prevalent (affects 33- 87% of hospitalized and 37% of non-hospitalized COVID patients), the pathophysiology of long-COVID is still not well understood. It is speculated that long-COVID patients have POTS or some other immune-mediated dysautonomia.  


Retrospective analysis approved by UT Southwestern IRB.  We identified 50 patients from our large COVID Recover clinic who were referred to the UT Southwestern autonomic laboratory for testing. Prior to testing, all patients were evaluated with supine and standing orthostatic vitals and completed symptom questionnaires.


Of 50 long-COVID patients who underwent standard autonomic testing, 24 patients had normal testing, 6 met heart rate criteria for POTS (by tilt table), 1 had severe diffuse autonomic failure with neurogenic orthostatic hypotension, 3 had mild length-dependent sudomotor impairment, 8 had mildly abnormal testing attributable to medication effects, 10 had mild non-specific autonomic impairment. The median CASS score was 0 (mean 1.0, range 0-8). The mean COMPASS-31 score was 43.4 (n= 43 patients), indicating severe symptoms. This score was similar in severity to previously studied POTS cohort (COMPASS 31 46.01, n= 205).


Although these long-COVID patients had severe symptoms, majority of patients had normal autonomic function tests or non-specific mild abnormalities (86%). Only 12% had testing consistent with POTS, 20% had mild non-specific autonomic dysfunction, and 2% had significant autonomic failure.  This is the largest cohort to date of autonomic testing in patients with long-COVID.  Long-COVID symptoms are usually not associated with POTS or other clear evidence of autonomic dysfunction.