Dysautonomia following COVID-19 is not associated with subjective limitations or symptoms but is associated with objective functional limitations

Peter Ladlow, Oliver O'Sullivan, Andrew Houston, Robert Barker-Davies, Samantha May, Daniel Mills, Dominic Dewson, Rebecca Chamley, Jon Naylor, Joseph Mulae, Alexander N. Bennett, Edward D. Nicol, David A. Holdsworth

Research output: Contribution to journalArticlepeer-review

53 Citations (SciVal)


Background: Individuals who contract coronavirus disease 2019 (COVID-19) can suffer with persistent and debilitating symptoms long after the initial acute illness. Heart rate (HR) profiles determined during cardiopulmonary exercise testing (CPET) and delivered as part of a post-COVID recovery service may provide insight into the presence and impact of dysautonomia on functional ability. Objective: Using an active, working-age, post–COVID-19 population, the purpose of this study was to (1) determine and characterize any association between subjective symptoms and dysautonomia; and (2) identify objective exercise capacity differences between patients classified “with” and those “without” dysautonomia. Methods: Patients referred to a post–COVID-19 service underwent comprehensive clinical assessment, including self-reported symptoms, CPET, and secondary care investigations when indicated. Resting HR >75 bpm, HR increase with exercise <89 bpm, and HR recovery <25 bpm 1 minute after exercise were used to define dysautonomia. Anonymized data were analyzed and associations with symptoms, and CPET outcomes were determined. Results: Fifty-one of the 205 patients (25%) reviewed as part of this service evaluation had dysautonomia. There were no associations between symptoms or perceived functional limitation and dysautonomia (P >.05). Patients with dysautonomia demonstrated objective functional limitations with significantly reduced work rate (219 ± 37 W vs 253 ± 52 W; P <.001) and peak oxygen consumption (V̇O2: 30.6 ± 5.5 mL/kg/min vs 35.8 ± 7.6 mL/kg/min; P <.001); and a steeper (less efficient) V̇E/V̇CO2 slope (29.9 ± 4.9 vs 27.7 ± 4.7; P = .005). Conclusion: Dysautonomia is associated with objective functional limitations but is not associated with subjective symptoms or limitation.

Original languageEnglish
Pages (from-to)613-620
Number of pages8
JournalHeart Rhythm
Issue number4
Early online date9 Dec 2021
Publication statusPublished - 30 Apr 2022

Bibliographical note

Funding Information:
The authors would like to thank the patients who attended the Defence Medical Services COVID-19 Recovery Service (DCRS) for their determination and positive engagement during the cardiopulmonary exercise test. We also acknowledge the tireless efforts of all the support staff at the Defence Medical Rehabilitation Centre. Data have been collected from serving UK Armed Forces personnel. As such, their data are sensitive and will not be published on an open registry. Requests for the anonymized data used for analysis can be directed to the corresponding author, who will liaise with the appropriate authority for consideration. Funding Sources: The authors have no funding sources to disclose. Disclosures: The authors have no conflicts of interest to disclose.


  • Cardiopulmonary exercise testing
  • COVID-19
  • Dysautonomia
  • Exercise testing
  • Symptoms

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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