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Durstenfeld MS, Peluso MJ, Spinelli MA, Li D, Hoh R, Gandhi M, Henrich TJ, Aras MA, Long CS, Deeks SG, Hsue PY. Association of SARS-CoV-2 Infection and Cardiopulmonary Long COVID with Exercise Capacity and Chronotropic Incompetence among People with HIV. medRxiv 2023:2023.05.01.23289358. [PMID: 37205522 PMCID: PMC10187359 DOI: 10.1101/2023.05.01.23289358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Long COVID has been associated with reduced exercise capacity, but whether SARS-CoV-2 infection or Long COVID is associated with reduced exercise capacity among people with HIV (PWH) has not been reported. We hypothesized that PWH with cardiopulmonary post-acute symptoms of COVID-19 (PASC) would have reduced exercise capacity due to chronotropic incompetence. Methods We conducted cross-sectional cardiopulmonary exercise testing within a COVID recovery cohort that included PWH. We evaluated associations of HIV, prior SARS-CoV-2 infection, and cardiopulmonary PASC with exercise capacity (peak oxygen consumption, VO 2 ) and adjusted heart rate reserve (AHRR, chronotropic measure) with adjustment for age, sex, and body mass index. Results We included 83 participants (median age 54, 35% female). All 37 PWH were virally suppressed; 23 (62%) had prior SARS-CoV-2 infection, and 11 (30%) had PASC. Peak VO 2 was reduced among PWH (80% predicted vs 99%; p=0.005), a difference of 5.5 ml/kg/min (95%CI 2.7-8.2, p<0.001). Chronotropic incompetence more prevalent among PWH (38% vs 11%; p=0.002), and AHRR was reduced among PWH (60% vs 83%, p<0.0001). Among PWH, exercise capacity did not vary by SARS-CoV-2 coinfection, but chronotropic incompetence was more common among PWH with PASC: 3/14 (21%) without SARS-CoV-2, 4/12 (25%) with SARS-CoV-2 without PASC, and 7/11 (64%) with PASC (p=0.04 PASC vs no PASC). Conclusions Exercise capacity and chronotropy are lower among PWH compared to SARS-CoV-2 infected individuals without HIV. Among PWH, SARS-CoV-2 infection and PASC were not strongly associated with reduced exercise capacity. Chronotropic incompetence may be a mechanism limiting exercise capacity among PWH.
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Gebo KA, Heath SL, Fukuta Y, Zhu X, Baksh S, Abraham AG, Habtehyimer F, Shade D, Ruff J, Ram M, Laeyendecker O, Fernandez RE, Patel EU, Baker OR, Shoham S, Cachay ER, Currier JS, Gerber JM, Meisenberg B, Forthal DN, Hammitt LL, Huaman MA, Levine A, Mosnaim GS, Patel B, Paxton JH, Raval JS, Sutcliffe CG, Anjan S, Gniadek T, Kassaye S, Blair JE, Lane K, McBee NA, Gawad AL, Das P, Klein SL, Pekosz A, Casadevall A, Bloch EM, Hanley D, Tobian AAR, Sullivan DJ. Early Treatment, Inflammation and Post-COVID Conditions. medRxiv 2023:2023.02.13.23285855. [PMID: 36824860 PMCID: PMC9949202 DOI: 10.1101/2023.02.13.23285855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Background Post-COVID conditions (PCC) are common and have significant morbidity. Risk factors for PCC include advancing age, female sex, obesity, and diabetes mellitus. Little is known about early treatment, inflammation, and PCC. Methods Among 883 individuals with confirmed SARS-CoV-2 infection participating in a randomized trial of CCP vs. control plasma with available biospecimens and symptom data, the association between early COVID treatment, cytokine levels and PCC was evaluated. Cytokine and chemokine levels were assessed at baseline, day 14 and day 90 using a multiplexed sandwich immuosassay (Mesoscale Discovery). Presence of any self-reported PCC symptoms was assessed at day 90. Associations between COVID treatment, cytokine levels and PCC were examined using multivariate logistic regression models. Results One-third of the 882 participants had day 90 PCC symptoms, with fatigue (14.5%) and loss of smell (14.5%) being most common. Cytokine levels decreased from baseline to day 90. In a multivariable analysis including diabetes, body mass index, race, and vaccine status, female sex (adjusted odds ratio[AOR]=2.70[1.93-3.81]), older age (AOR=1.32[1.17-1.50]), and elevated baseline levels of IL-6 (AOR=1.59[1.02-2.47]) were associated with development of PCC.There was a trend for decreased PCC in those with early CCP treatment (≤5 days after symptom onset) compared to late CCP treatment. Conclusion Increased IL-6 levels were associated with the development of PCC and there was a trend for decreased PCC with early CCP treatment in this predominately unvaccinated population. Future treatment studies should evaluate the effect of early treatment and anti-IL-6 therapies on PCC development.
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Affiliation(s)
- Kelly A Gebo
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Sonya L Heath
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Yuriko Fukuta
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX
| | - Xianming Zhu
- Department of Pathology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Sheriza Baksh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Alison G Abraham
- Department of Epidemiology, University of Colorado, Anschutz Medical Campus, Aurora CO
| | - Feben Habtehyimer
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - David Shade
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jessica Ruff
- Department of Pathology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Malathi Ram
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH
| | - Reinaldo E Fernandez
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Owen R Baker
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Shmuel Shoham
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Edward R Cachay
- Department of Medicine, Division of Infectious Diseases, University of California, San Diego, San Diego, CA
| | - Judith S Currier
- Department of Medicine, Division of Infectious Diseases, University of California, Los Angeles, Los Angeles, CA
| | - Jonathan M Gerber
- Department of Medicine, Division of Hematology and Oncology, University of Massachusetts, Worchester, MA
| | | | - Donald N Forthal
- Department of Medicine, Division of Infectious Diseases, University of California, Irvine, Irvine, CA
| | - Laura L Hammitt
- International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Moises A Huaman
- Department of Medicine, Division of Infectious Diseases University of Cincinnati, Cincinnati, OH
| | - Adam Levine
- Department of Emergency Medicine, Rhode Island Hospital Warren Alpert Medical School of Brown University, Providence, RI
| | - Giselle S Mosnaim
- Division of Allergy and Immunology, Department of Medicine, Northshore University Health System, Evanston, IL
| | - Bela Patel
- Department of Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, Houston, TX
| | - James H Paxton
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM
| | - Catherine G Sutcliffe
- International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Shweta Anjan
- Department of Medicine, Department of Medicine, Division of Infectious Diseases, University of Miami, Miller School of Medicine, Miami, FL
| | - Thomas Gniadek
- Department of Pathology, Northshore University Health System, Evanston, IL
| | - Seble Kassaye
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Janis E Blair
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, AZ
| | - Karen Lane
- Department of Neurology, Brain Injury Outcomes Division, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Nichol A McBee
- Department of Neurology, Brain Injury Outcomes Division, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Amy L Gawad
- Department of Neurology, Brain Injury Outcomes Division, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Piyali Das
- Department of Neurology, Brain Injury Outcomes Division, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Sabra L Klein
- Division of Infectious Diseases, Medstar Georgetown University Hospital, Washington, D.C
| | - Andrew Pekosz
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Daniel Hanley
- Department of Neurology, Brain Injury Outcomes Division, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Lai CC, Hsu CK, Yen MY, Lee PI, Ko WC, Hsueh PR. Long COVID: An inevitable sequela of SARS-CoV-2 infection. J Microbiol Immunol Infect 2023; 56:1-9. [PMID: 36283919 PMCID: PMC9576029 DOI: 10.1016/j.jmii.2022.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/25/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
At present, there are more than 560 million confirmed cases of the coronavirus disease 2019 (COVID-19) worldwide. Although more than 98% of patients with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection can survive acute COVID, a significant portion of survivors can develop residual health problems, which is termed as long COVID. Although severe COVID-19 is generally associated with a high risk of long COVID, patients with asymptomatic or mild disease can also show long COVID. The definition of long COVID is inconsistent and its clinical manifestations are protean. In addition to general symptoms, such as fatigue, long COVID can affect many organ systems, including the respiratory, neurological, psychosocial, cardiovascular, gastrointestinal, and metabolic systems. Moreover, patients with long COVID may experience exercise intolerance and impaired daily function and quality of life. Long COVID may be caused by SARS-CoV-2 direct injury or its associated immune/inflammatory response. Assessment of patients with long COVID requires comprehensive evaluation, including history taking, physical examination, laboratory tests, radiography, and functional tests. However, there is no known effective treatment for long COVID. Based on the limited evidence, vaccines may help to prevent the development of long COVID. As long COVID is a new clinical entity that is constantly evolving, there are still many unknowns, and further investigation is warranted to enhance our understanding of this disease.
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Affiliation(s)
- Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chi-Kuei Hsu
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Muh-Yong Yen
- Division of Infectious Diseases, Cheng Hsin General Hospital, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ping-Ing Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan,Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan,School of Medicine, China Medical University, Taichung, Taiwan,Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan,Corresponding author. Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, China Medical University, No. 2, Yude Road, North District, Taichung 40447, Taiwan
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Durstenfeld MS, Sun K, Tahir P, Peluso MJ, Deeks SG, Aras MA, Grandis DJ, Long CS, Beatty A, Hsue PY. Use of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2236057. [PMID: 36223120 PMCID: PMC9557896 DOI: 10.1001/jamanetworkopen.2022.36057] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Reduced exercise capacity is commonly reported among individuals with COVID-19 symptoms more than 3 months after SARS-CoV-2 infection (long COVID-19 [LC]). Cardiopulmonary exercise testing (CPET) is the criterion standard to measure exercise capacity and identify patterns of exertional intolerance. OBJECTIVES To estimate the difference in exercise capacity among individuals with and without LC symptoms and characterize physiological patterns of limitations to elucidate possible mechanisms of LC. DATA SOURCES A search of PubMed, EMBASE, Web of Science, preprint servers, conference abstracts, and cited references was performed on December 20, 2021, and again on May 24, 2022. A preprint search of medrxiv.org, biorxiv.org, and researchsquare.com was performed on June 9, 2022. STUDY SELECTION Studies of adults with SARS-CoV-2 infection more than 3 months earlier that included CPET-measured peak oxygen consumption (V̇o2) were screened independently by 2 blinded reviewers; 72 (2%) were selected for full-text review, and 35 (1%) met the inclusion criteria. An additional 3 studies were identified from preprint servers. DATA EXTRACTION AND SYNTHESIS Data extraction was performed by 2 independent reviewers according to the PRISMA reporting guideline. Data were pooled using random-effects models. MAIN OUTCOMES AND MEASURES Difference in peak V̇o2 (in mL/kg/min) among individuals with and without persistent COVID-19 symptoms more than 3 months after SARS-CoV-2 infection. RESULTS A total of 38 studies were identified that performed CPET on 2160 individuals 3 to 18 months after SARS-CoV-2 infection, including 1228 with symptoms consistent with LC. Most studies were case series of individuals with LC or cross-sectional assessments within posthospitalization cohorts. Based on a meta-analysis of 9 studies including 464 individuals with LC symptoms and 359 without symptoms, the mean peak V̇o2 was -4.9 (95% CI, -6.4 to -3.4) mL/kg/min among those with symptoms with a low degree of certainty. Deconditioning and peripheral limitations (abnormal oxygen extraction) were common, but dysfunctional breathing and chronotropic incompetence were also described. The existing literature was limited by small sample sizes, selection bias, confounding, and varying symptom definitions and CPET interpretations, resulting in high risk of bias and heterogeneity. CONCLUSIONS AND RELEVANCE The findings of this systematic review and meta-analysis study suggest that exercise capacity was reduced more than 3 months after SARS-CoV-2 infection among individuals with symptoms consistent with LC compared with individuals without LC symptoms, with low confidence. Potential mechanisms for exertional intolerance other than deconditioning include altered autonomic function (eg, chronotropic incompetence, dysfunctional breathing), endothelial dysfunction, and muscular or mitochondrial pathology.
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Affiliation(s)
- Matthew S. Durstenfeld
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Kaiwen Sun
- Department of Medicine, University of California, San Francisco
| | - Peggy Tahir
- UCSF Library, University of California, San Francisco
| | - Michael J. Peluso
- Department of Medicine, University of California, San Francisco
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Mandar A. Aras
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, UCSF Health, University of California, San Francisco
| | - Donald J. Grandis
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, UCSF Health, University of California, San Francisco
| | - Carlin S. Long
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, UCSF Health, University of California, San Francisco
| | - Alexis Beatty
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, UCSF Health, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Priscilla Y. Hsue
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, Zuckerberg San Francisco General Hospital, San Francisco, California
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Durstenfeld MS, Sun K, Tahir PM, Peluso MJ, Deeks SG, Aras MA, Grandis DJ, Long CS, Beatty A, Hsue PY. Cardiopulmonary exercise testing to evaluate post-acute sequelae of COVID-19 ("Long COVID"): a systematic review and meta-analysis. medRxiv 2022:2022.06.15.22276458. [PMID: 35734081 PMCID: PMC9216726 DOI: 10.1101/2022.06.15.22276458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
IMPORTANCE Reduced exercise capacity is commonly reported among individuals with Long COVID (LC). Cardiopulmonary exercise testing (CPET) is the gold-standard to measure exercise capacity to identify causes of exertional intolerance. OBJECTIVES To estimate the effect of SARS-CoV-2 infection on exercise capacity including those with and without LC symptoms and to characterize physiologic patterns of limitations to elucidate possible mechanisms of LC. DATA SOURCES We searched PubMed, EMBASE, and Web of Science, preprint severs, conference abstracts, and cited references in December 2021 and again in May 2022. STUDY SELECTION We included studies of adults with SARS-CoV-2 infection at least three months prior that included CPET measured peak VO 2 . 3,523 studies were screened independently by two blinded reviewers; 72 (2.2%) were selected for full-text review and 36 (1.2%) met the inclusion criteria; we identified 3 additional studies from preprint servers. DATA EXTRACTION AND SYNTHESIS Data extraction was done by two independent reviewers according to PRISMA guidelines. Data were pooled with random-effects models. MAIN OUTCOMES AND MEASURES A priori primary outcomes were differences in peak VO 2 (in ml/kg/min) among those with and without SARS-CoV-2 infection and LC. RESULTS We identified 39 studies that performed CPET on 2,209 individuals 3-18 months after SARS-CoV-2 infection, including 944 individuals with LC symptoms and 246 SARS-CoV-2 uninfected controls. Most were case-series of individuals with LC or post-hospitalization cohorts. By meta-analysis of 9 studies including 404 infected individuals, peak VO 2 was 7.4 ml/kg/min (95%CI 3.7 to 11.0) lower among infected versus uninfected individuals. A high degree of heterogeneity was attributable to patient and control selection, and these studies mostly included previously hospitalized, persistently symptomatic individuals. Based on meta-analysis of 9 studies with 464 individuals with LC, peak VO 2 was 4.9 ml/kg/min (95%CI 3.4 to 6.4) lower compared to those without symptoms. Deconditioning was common, but dysfunctional breathing, chronotropic incompetence, and abnormal oxygen extraction were also described. CONCLUSIONS AND RELEVANCE These studies suggest that exercise capacity is reduced after SARS-CoV-2 infection especially among those hospitalized for acute COVID-19 and individuals with LC. Mechanisms for exertional intolerance besides deconditioning may be multifactorial or related to underlying autonomic dysfunction.
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