Minimal Objective Autonomic Dysfunction in Long COVID

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Long COVID (n=128). Intervention: Long COVID with autonomic symptoms. Primary outcome: Objective autonomic abnormalities on standardized autonomic reflex function testing.

Q: What does this research mean for the field?

Objective autonomic dysfunction is uncommon in long COVID patients despite a high subjective burden of autonomic symptoms. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Meredith A. Bryarly; Nathaniel M. Robbins; Mark Roberts; Christina Y. Martin; Roberto Sergio Hernandez; Surendra Barshikar; Steven A. Vernino

doi:10.1016/j.jacc.2025.04.038

August 27, 2025Journal of the American College of CardiologyOpen Access

Minimal Objective Autonomic Dysfunction in Long COVID

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Key result

Long COVID shows low objective autonomic impairment, with excessive orthostatic tachycardia in only ~16% of patients.

n=128

Key Points

To determine the prevalence of objective autonomic reflex abnormalities in patients with long COVID presenting with symptoms suggestive of dysautonomia.
Retrospective review of N=128 patients with long COVID referred for formal testing between September 2021 and February 2023 across two academic medical centers (UT Southwestern and Dartmouth-Hitchcock).
Standardized autonomic reflex testing included quantitative sudomotor axon reflex testing (QSART), heart rate and blood pressure responses to Valsalva and deep breathing, and 10-minute head-up tilt or active standing.
Symptom severity and autonomic impairment were quantified using COMPASS-31 and Composite Autonomic Severity Score (CASS) metrics.
Most patients (105 of 128) had normal testing or mild nonspecific abnormalities, yielding a cohort median CASS score of 1.2 despite a high median COMPASS-31 symptom score of 45.7.
Excessive orthostatic tachycardia meeting criteria for POTS was identified in 20 of 128 patients (15.6%), of whom 3 had a preexisting POTS diagnosis prior to COVID-19 infection.
Autonomic failure was present in 3 of 128 patients, all of whom carried the diagnosis before COVID-19, and 10 patients with self-reported POTS had normal autonomic testing.

Study Design

Type

Observational (n=128)

Multicenter

Yes

Structured PICO

P

Population

128 patients with long COVID and high autonomic symptom burden referred for formal autonomic reflex testing at two tertiary-care centers.

E

Exposure

Standardized autonomic reflex function testing (ART)

O

Outcome

Objective autonomic abnormalities categorized by ART results (normal, mild/nonspecific changes, POTS, peripheral autonomic neuropathy, autonomic failure)surrogate

Limitations

Retrospective design
Referring clinician's discretion in ordering ART
May not generalize to nontertiary care and non-U.S. populations
retrospective design
referring clinician's discretion in ordering ART
may not generalize to nontertiary care and non-U.S. populations

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Implication

Despite a high burden of autonomic symptoms in patients with long COVID, objective autonomic dysfunction on formal testing is rare, suggesting symptoms may be driven by other mechanisms.

Abstract

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Cite This Study

Bryarly et al. (2025) conducted an observational in Long COVID (n=128). Long COVID with autonomic symptoms was evaluated on Objective autonomic abnormalities on standardized autonomic reflex function testing. Significant objective autonomic abnormalities are uncommon in long COVID, with only 15.6% of patients demonstrating excessive orthostatic tachycardia and the vast majority having normal or mild nonspecific findings.

synapsesocial.com/papers/6ab2f016e4c65bb1bcec509d https://doi.org/10.1016/j.jacc.2025.04.038

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Minimal Objective Autonomic Dysfunction in Long COVID

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Minimal Objective Autonomic Dysfunction in Long COVID

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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