Post-COVID Dysautonomia: A Narrative Review of Pathophysiology, Clinical Manifestations, and Emerging Management Strategies

Post-COVID dysautonomia has emerged as a prominent and debilitating manifestation of Long COVID, characterized by a wide spectrum of autonomic dysfunctions including postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, and gastrointestinal dysmotility. Despite growing recognition, the pathophysiological underpinnings, clinical presentation, and optimal management of this condition remain incompletely understood.This narrative review aims to synthesize current evidence on the mechanisms, clinical features, diagnostic approaches, and emerging therapeutic strategies for dysautonomia following SARS-CoV-2 infection, while highlighting knowledge gaps and future research directions.A comprehensive literature review was conducted using PubMed, Scopus, and Google Scholar to identify peer-reviewed studies, reviews, and case series relevant to post-COVID autonomic dysfunction. Articles published between 2020 and 2025 were included, with emphasis on mechanistic insights, clinical case definitions, and management outcomes.Multiple pathophysiological mechanisms are implicated, including autoimmune activation, persistent neuroinflammation, vagal nerve injury, endothelial dysfunction, and residual viral reservoirs. Clinically, patients may present with multisystemic symptoms that overlap with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Diagnostic workup includes autonomic function testing, tilt-table testing, and biomarker evaluation. Emerging treatment modalities range from beta-blockers and volume expansion to neuromodulation and immunotherapy, though evidence remains limited and heterogeneous.Post-COVID dysautonomia represents a complex, multifactorial condition with significant implications for patient quality of life. Improved diagnostic criteria, mechanistic biomarkers, and randomized controlled trials are urgently needed to guide management and therapeutic development. Interdisciplinary collaboration will be critical in addressing the growing burden of autonomic dysfunction in the post-pandemic era.