Autonomic Dysfunction as a Potential Pathophysiological Link Between Chronic Low Back Pain and Coronary Artery Disease: A Systematic Review

Chronic low back pain (CLBP) is a leading cause of disability worldwide and is increasingly recognized as a condition associated with systemic physiological alterations beyond musculoskeletal dysfunction. Emerging evidence suggests that autonomic nervous system dysregulation may be associated with impaired cardiovascular regulation and increased cardiovascular risk in individuals with CLBP. This systematic review aimed to evaluate the current evidence regarding autonomic dysfunction in CLBP and its potential association with cardiovascular disease. A comprehensive literature search was conducted according to the PRISMA 2020 guidelines across PubMed/MEDLINE, Scopus, Web of Science, EMBASE, CENTRAL, CINAHL, EBSCOhost, and Google Scholar from database inception through January 2026, along with gray literature sources. Studies evaluating autonomic or cardiovascular autonomic function in adults with CLBP were included. A total of 10 studies met the inclusion criteria. Most studies demonstrated reduced heart rate variability, diminished vagal activity, sympathetic predominance, impaired autonomic regulation, and delayed cardiovascular recovery in individuals with CLBP compared with healthy controls. Several studies also reported associations between autonomic dysfunction and pain-related disability, catastrophizing, kinesiophobia, and altered pain modulation. Population-based evidence suggested increased prevalence of coronary heart disease and myocardial infarction among individuals with CLBP, while interventional studies demonstrated improvements in autonomic regulation following yoga-based rehabilitation and spinal manipulative therapy. Overall, the certainty of evidence ranged from low to moderate because of methodological heterogeneity and the predominance of observational study designs. Current evidence suggests that CLBP is associated with clinically relevant autonomic and cardiovascular alterations. These findings highlight the importance of incorporating autonomic and cardiovascular assessment into multidisciplinary management strategies while emphasizing the need for further prospective and mechanistic research.