Autonomic dysfunction in COVID-19 patients receiving mechanical ventilation: A cross-sectional study

Silva, Renata Baltar da; Neves, Victor Ribeiro; Barros, Mayara Costa; Gambassi, Bruno Bavaresco; Schwingel, Paulo Adriano; Sobral Filho, Dário Celestino

doi:10.1590/1516-3180.2022.0513.R1.09022023

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Original Article • Sao Paulo Med. J. 141 (6) • 2023 • https://doi.org/10.1590/1516-3180.2022.0513.R1.09022023 linkcopy

Autonomic dysfunction in COVID-19 patients receiving mechanical ventilation: A cross-sectional study

Authorship SCIMAGO INSTITUTIONS RANKINGS

BACKGROUND: Coronavirus disease 2019 (COVID-19) can damage cardiac tissue by increasing troponin levels and inducing arrhythmias, myocarditis, and acute coronary syndrome.

OBJECTIVES: To analyze the impact of COVID-19 on cardiac autonomic control in mechanically ventilated intensive care unit (ICU) patients.

DESIGN AND SETTING: This cross-sectional analytical study of ICU patients of both sexes receiving mechanical ventilation was conducted in a tertiary hospital.

METHODS: Patients were divided into COVID-19-positive (COVID(+)) and COVID-19-negative (COVID(-)) groups. Clinical data were collected and heart rate variability (HRV) records obtained using a heart rate monitor.

RESULTS: The study sample comprised 82 subjects: 36 (44%) in the COVID(-) group (58.3% female; median age, 64.5 years) and 46 (56%) in the COVID(+) group (39.1% females; median age, 57.5 years). The HRV indices were lower than the reference values. An intergroup comparison identified no statistically significant differences in the mean normal-to-normal (NN) interval, standard deviation of the NN interval, or root mean square of successive differences in NN intervals. The COVID(+) group had an increased low frequency (P = 0.05), reduced high frequency (P = 0.045), and increased low frequency/high frequency (LF/HF) ratio (P = 0.048). There was a weak positive correlation between LF/HF and length of stay in the COVID(+) group.

CONCLUSION: Patients who received mechanical ventilation had lower overall HRV indices. COVID(+) patients who received mechanical ventilation had lower vagal HRV components. These findings likely indicate clinical applicability, as autonomic control impairments are associated with a greater risk of cardiac death.

KEYWORDS (MeSH terms):
Autonomic nervous system; Heart rate; SARS-CoV-2; Critical care

AUTHOR'S KEYWORDS:
Heart rate variability; Intensive care unit; Mechanical ventilatory assistance

Variables	Negative COVID (n = 36)	Positive COVID (n = 46)	P
Variables	Median (1Q–3Q) [Min-Max]	Median (1Q–3Q) [Min-Max]	P
Age, years	64.5 (56.0–70.0)[28.0–81.0]	57.5 (42.8–73.0)[31.0–88.0]	0.472
Heart rate, bpm	93.0 (81.3–101.0)[58.0–119.0]	88.0 (73.0–104.0)[55.0–147.0]	0.492
Systolic blood pressure, mmHg	137.0 (113.8–156.5)[67.0 - 189.0]	128.5 (108.8–142.5)[64.0–166.0]	0.071
Diastolic blood pressure, mmHg	74.5 (66.3–86.8)[47.0–100.0]	69.5 (60.0–84.0)[48.0–117.0]	0.184
Peripheral capillary oxygen saturation, %	97.0 (95.0–98.0)[93.0–100.0]	95.5 (94.0–98.0)[91.0–100.0]	0.035
Length in intensive care unit, days	5.0 (3.0–10.8)[1.0–26.0]	9.0 (4.0–14.0)[1.0–34.0]	0.024
Positive end-expiratory pressure, cmH²O	6 (6–8)[5–10]	6 (6–8)[5–10]	0.795
Pressure support, cmH²O	10 (10–10)[8–18]	10 (10–12)[8–16]	0.682
Fraction of inspired oxygen, %	21 (21–30)[21–35]	25 (21–35)[21–50]	0.024
PaO²/FiO² ratio	366 (310–471)[201–666]	356 (277–419)[140–633]	0.168
Maximal inspiratory pressure, cmH²O	-60 (-47 – -80)[-20 – -120]	-60 (-60 – -100)[-30 – -120]	0.282
Maximal expiratory pressure, cmH²O	80 (46–100)[20 – 170]	70 (48–100)[20–150]	0.828
Rapid shallow breath index	44 (36–66)[12–110]	46 (37–66)[24–85]	0.602
Female sex, n (%)	21 (58.3%)	18 (39.1%)	0.084
Systemic arterial hypertension, n (%)	24 (66.7%)	24 (52.2%)	0.186
Diabetes mellitus, n (%)	19 (52.8%)	18 (39.1%)	0.218
Chronic obstructive pulmonary disease, n (%)	6 (16.7%)	5 (10.9%)	0.523

Variables	Negative COVID (n = 36)	Positive COVID (n = 46)	P
Variables	Median (1Q–3Q) [Min-Max]	Median (1Q–3Q) [Min-Max]	P
NNi medium, ms	639.5 (572.3–764.8)[451.0–1191.0]	653.0 (571.8–800.8)[8.6–1321.0]	0.581
SDNN, ms	8.1 (4.5–25.9)[3.0–65.0]	10.4 (6.2–21.3)[2.5–46.3]	0.562
RMSSD, ms	12.1 (4.5–32.2)[2.1–98.0]	12.9 (7.9–27.3)[2.0–68.6]	0.695
LF, nu	33.6 (24.8–55.4)[9.2–87.2]	47.2 (26.4–71.0)[7.2–87.8]	0.050
HF, nu	66.8 (44.3–74.9)[12.8–90.2]	51.4 (28.9–71.8)[12.2–91.4]	0.045
LF/HF ratio	0.5 (0.3–1.3)[0.1–6.8]	0.9 (0.4–2.5)[0.1–7.2]	0.048

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[TFN1] COVID-19 = coronavirus disease 2019; 1Q = first quartile; 3Q = third quartile; Min-Max = minimum-maximum; PaO² = oxygen blood pressure; FiO2 = fraction of inspired oxygen.