The ongoing COVID-19 outbreak raises new management challenges, which lack an evidence-based answer to date. The management group of the EAN Scientific Panel for Autonomic Nervous System (ANS) Disorders discusses below some management aspects relevant to patients with autonomic disorders.
Are patients with autonomic disorders at “high-risk”?
Autonomic disorders, or their treatment, may place the patient at a greater risk of contracting infections or of a more severe course.
Risk stratification is determined by:
- The cause of the autonomic disorder, e.g. diabetes mellitus;
- Accompanying symptoms in diseases such as multiple system atrophy, in which patients are prone to developing more severe cardiovascular, respiratory, and gastrointestinal problems including altered swallowing;
- Use of immunomodulatory agents to treat immune-mediated forms of autonomic failure.
Telemedicine with audio- or video-support should be widely encouraged for patients with autonomic disorders requiring closer medical advice and support. Efforts should be undertaken at local level to regulate telemedicine services.
Should we adjust the therapeutic regimens of the patients under our care?
Currently there are no conclusive data on any increased or mitigated risk of cardiovascular medications, particularly angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers1, and therefore such medications should not be changed.
For patients with an autonomic nervous system disorder using non-steroidal anti-inflammatory drugs (e.g. ibuprofen), or corticosteroids, who develop COVID-19, continued use of these medications should be carefully discussed with an autonomic nervous system specialist on a individualized basis. So far, there are not enough conclusive data to provide a more generalized recommendation.
Are there any acute autonomic consequences of Sars-Cov2 infections?
During COVID-19 infection, intense coughing may trigger reflex syncope.
Dehydration and fluid loss may exacerbate orthostatic hypotension and increase the risk of syncope and falls.
Recent studies report on neurotropism of SarsCov22 and involvement of the brainstem cardiorespiratory nuclei has been speculated3: it is possible that this could place affected patients at higher risk for central ventilatory disorders.
Are there any mid- or long-term autonomic consequences of Sars-Cov2 infections?
Orthostatic intolerance and syncope frequently result from viral illnesses due to gastrointestinal fluid loss, prolonged bed rest and deconditioning of the cardiovascular and viscero-sensory systems after the acute illness. Although large-scale epidemiological data on convalescent COVID-19 patients are lacking, it is conceivable that conditions such as orthostatic hypotension or postural orthostatic tachycardia syndrome (POTS) may occur in patients recovering from COVID-19 infections.
To date, it is unknown how often and to what extent COVID-19 infection will be associated with acute or prolonged lesions of cardiorespiratory brainstem areas.
We kindly invite colleagues treating COVID-19 patients to share their experience. The management group of the EAN Scientific Panel for ANS Disorders remains available to provide remote advice on autonomic complications.
Alessandra Fanciulli, Mario Habek, Diogo Carneiro, Jalesh N. Panicker, Walter Struhal, Max J. Hilz
Management Group of the EAN Scientific Panel for ANS disorders
1 Kuster GM, Pfister O, Burkard T, Zhou Q, Twerenbold R, Haaf P, Widmer AF, Osswald S SARS-CoV2: should inhibitors of the renin-angiotensin system be withdrawn in patients with COVID-19? Eur Heart J. 2020 Mar 20
2 Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, Chang J, Hong C, Zhou Y, Wang D, Miao X, Li Y, Hu B Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020 Apr 10
3 Li YC, Bai WZ, Hashikawa T The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients J Med Virol. 2020;1–4