Impact of the COVID-19 pandemic on clinical autonomic practice in Europe A survey of the European Academy of Neurology (EAN) and the European Federation of Autonomic Societies (EFAS)

Alessandra Fanciulli; Fabian Leys; Magdalena Krbot Skorić; Diogo Reis Carneiro; Giovanna Calandra-Buonaura; Jennifer Camaradou; Giacomo Chiaro; Pietro Cortelli; Cristian Falup-Pecurariu; Roberta Granata; Pietro Guaraldi; Raimund Helbok; Max J Hilz; Valeria Iodice; Jens Jordan; Evert C A Kaal; Anita Kamondi; Anne Pavy Le Traon; Isabel Rocha; Johann Sellner; Jean Michel Senard; Astrid Terkelsen; Gregor K Wenning; Elena Moro; Thomas Berger; Roland D Thijs; Walter Struhal; Mario Habek; Collaborators of European Network of Neurological ANS laboratories

doi:10.1111/ene.15787

Impact of the COVID-19 pandemic on clinical autonomic practice in Europe A survey of the European Academy of Neurology (EAN) and the European Federation of Autonomic Societies (EFAS)

Eur J Neurol. 2023 Mar 15. doi: 10.1111/ene.15787. Online ahead of print.

Authors

Alessandra Fanciulli¹, Fabian Leys¹, Magdalena Krbot Skorić^{2

3}, Diogo Reis Carneiro^{4

5}, Giovanna Calandra-Buonaura^{6

7}, Jennifer Camaradou^{8

9}, Giacomo Chiaro^{10

11}, Pietro Cortelli^{6

7}, Cristian Falup-Pecurariu¹², Roberta Granata¹, Pietro Guaraldi⁶, Raimund Helbok^{1

13}, Max J Hilz^{14

15}, Valeria Iodice^{10

11}, Jens Jordan^{16

17}, Evert C A Kaal¹⁸, Anita Kamondi^{19

20}, Anne Pavy Le Traon²¹, Isabel Rocha²², Johann Sellner^{23

24}, Jean Michel Senard²⁵, Astrid Terkelsen²⁶, Gregor K Wenning¹, Elena Moro²⁷, Thomas Berger^{28

29}, Roland D Thijs^{30

31}, Walter Struhal³², Mario Habek^{2

33}; Collaborators of European Network of Neurological ANS laboratories

Affiliations

¹ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
² Department of Neurology, University Hospital Centre, Zagreb, Croatia.
³ Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia.
⁴ Department of Neurology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
⁵ Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
⁶ IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
⁷ Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
⁸ Patient partner of the EAN Scientific Panel for Autonomic Nervous System Disorders, London, UK.
⁹ UCL Social Research Institute, University College London, London, UK.
¹⁰ Autonomic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
¹¹ UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.
¹² Department of Neurology, Faculty of Medicine, Transilvania University, Brasov, Romania.
¹³ Department of Neurology, Kepler University Linz, Austria.
¹⁴ Icahn School of Medicine at Mount Sinai, New York, USA.
¹⁵ Department of Neurology, University Erlangen-, Nuremberg, Germany.
¹⁶ German Aerospace Center, Cologne, Germany.
¹⁷ Medical Faculty, University of Cologne, Germany.
¹⁸ Department of Neurology, Maasstad Ziekenhuis, Rotterdam, The Netherlands.
¹⁹ Department of Neurology, National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary.
²⁰ Department of Neurology, Semmelweis University, Budapest, Hungary.
²¹ Department of Neurology, Centre, Hospitalier Universitaire de Toulouse, Toulouse, France.
²² Cardiovascular Autonomic Function Lab, Faculty of Medicine and CCUL, University of Lisbon, Lisbon, Portugal.
²³ Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria.
²⁴ Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
²⁵ Institut des Maladies Métaboliques et Cardiovasculaires, INSERM U 1297, Toulouse, France.
²⁶ Department of Neurology, Aarhus University, Hospital and Danish Pain Research Center, Aarhus University, Aarhus, Denmark.
²⁷ Grenoble Alpes University, CHU of Grenoble, Division of Neurology, Grenoble Institut of Neuroscience, Grenoble, France.
²⁸ Department of Neurology, Medical University of Vienna, Vienna, Austria.
²⁹ Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria.
³⁰ Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
³¹ Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
³² Karl Landsteiner University of Health Sciences, Department of Neurology, University Hospital Tulln, Tulln, Austria.
³³ Department of Neurology, University of Zagreb, School of Medicine, Zagreb, Croatia.

PMID: 36920252
DOI: 10.1111/ene.15787

Abstract

Objective: To investigate the impact of the coronavirus-disease-2019 (COVID-19) pandemic on European clinical autonomic practice.

Methods: Eighty-four neurology-driven or interdisciplinary autonomic centers in 22 European countries were invited to fill in a web-based survey between September and November 2021.

Results: Forty-six centers completed the survey (55%). During the first pandemic year, the number of performed tilt-table tests, autonomic outpatient and inpatient visits decreased respectively by 50%, 45% and 53%, and every-third center reported major adverse events due to postponed examinations or visits. The most frequent newly-diagnosed or worsened cardiovascular autonomic disorders after COVID-19 infection included postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, and recurrent vasovagal syncope, deemed likely related to the infection by ≥50% of the responders. Forty-seven percent of the responders also reported about people with new-onset of orthostatic intolerance, but negative tilt-table findings, and 16% about people with psychogenic pseudosyncope after COVID-19. Most patients were treated non-pharmacologically and symptomatic recovery at follow-up was observed in ≥45% of cases. By contrast, low frequencies of newly-diagnosed cardiovascular autonomic disorders following COVID-19 vaccination were reported, most frequently POTS and recurrent vasovagal syncope, and most of the responders judged a causal association unlikely. Non-pharmacological measures were the preferred treatment choice, with 50-100% recovery rates at follow-up.

Conclusions: Cardiovascular autonomic disorders may develop or worsen following a COVID-19 infection, while the association with COVID-19 vaccines remains controversial. Despite the severe pandemic impact on European clinical autonomic practice, a specialized diagnostic work-up was pivotal to identify non-autonomic disorders in people with post-COVID-19 orthostatic complaints.

Keywords: COVID-19 infection; COVID-19 vaccination; POTS; autonomic nervous system; orthostatic hypotension; postural orthostatic tachycardia syndrome; syncope; telemedicine.