text: Autonomic dysfunction in long COVID rationale physiology and management strategies The SARS CoV 2 COVID 19 pandemic has caused unprecedented morbidity mortality and global disruption Following the initial surge of infections focus shifted to managing the longer term sequelae of illness in survivors Post acute COVID known colloquially as long COVID is emerging as a prevalent syndrome It encompasses a plethora of debilitating symptoms including breathlessness chest pain palpitations and orthostatic intolerance which can last for weeks or more following mild illness We describe a series of individuals with symptoms of long COVID and we posit that this condition may be related to a virus or immune mediated disruption of the autonomic nervous system resulting in orthostatic intolerance syndromes We suggest that all physicians should be equipped to recognise such cases appreciate the symptom burden and provide supportive management We present our rationale for an underlying impaired autonomic physiology post COVID 19 and suggest means of management 