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POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME (POTS)

POTS can be triggered by a variety of conditions, including viral or bacterial infections. Some researchers believe that coronavirus can be a trigger for POTS, as an increased number of people who recovered from COVID-19 are now experiencing POTS-like symptoms, such as brain fog, tachycardia (increased heart rate) and severe chronic fatigue. This similarity in symptoms led doctors to start testing patients for POTS.

Postural orthostatic tachycardia syndrome (POTS) is a common debilitating condition characterized by a sustained heart rate (HR) increment of ≥30 beats/min within 10 min of standing or head-up tilt in the absence of orthostatic hypotension. Associated symptoms typically include chest pain, palpitations, exercise intolerance, orthostatic intolerance and fatigue, gastrointestinal disturbance, headache, fibromyalgia and sleep disturbance. It commonly affects young women. When the autonomic nervous system (ANS) doesn’t work as it should, it can cause heart and blood pressure problems, trouble breathing and loss of bladder control.

Although many people recover quickly from COVID-19, the disease caused by the coronavirus, others who recover may continue to experience symptoms for months. Researchers are still determining the cause of these extended symptoms, but some COVID-19 "long-haulers" may actually be dealing with a known condition, called postural orthostatic tachycardia syndrome. This condition, also called POTS, affects involuntary nervous system functions, such as heart rate and blood pressure, usually upon standing from a reclining position.

You should talk to your doctor if you have had COVID-19 and are experiencing ongoing symptoms, including:

Severe fatigue, Extreme tiredness that won’t go away

Lightheadedness

Memory problems

Shakiness

Headaches

Chronic nausea and vomiting

intolerance to standing

A faster heart rate with slight increase in activity

Trouble thinking (brain fog)

Fainting or near-fainting

Temperature deregulation (hot or cold).

Blurred vision

Discoloration of feet and hands

Excessive or lack of sweating

Dizziness with Omicron (BA.2) with their subvariants

Your doctor will first try to rule out other complication. We must be careful with regard to diagnosing patients with POTS, as we know COVID-19 can cause blood clots or scars in the lungs, which can cause similar symptoms as POTS but would require very different treatment.

There is no one standard approach to post-COVID patients with POTS-like symptoms, and treatment should be personalized, based on the diagnosis. If POTS is confirmed, generally start aggressive hydration, dietary modifications and certain medications. Physical therapy is key, but it often takes months before patients respond to treatment sufficiently to be ready for a physical therapy regimen.

As with any viral infection, COVID-19 can temporarily worsen POTS symptoms, which could make recovery harder. Because this is a new disease, the long-term effects of COVID-19 in patients with POTS are not well known.

The COVID-19 pandemic has created a unique research opportunity for physicians interested in POTS. In many patients with POTS, it can be difficult to pin down the cause of the condition. In patients with POTS after COVID-19, the cause is clear, and researchers will be able to compare these patients with those who recovered fully from the virus. There’s hope that this cohort of patients will help further research into treatment for all people suffering from POTS.

The current proposed pathology for POTS is an inability to regulate blood volume. Researchers suspect that vasomotor denervation causes dilation of the blood vessels, leading to reduced preload to the heart, which triggers an increase in the central sympathetic nervous system response. Resulting symptoms are likely related to inadequate blood circulation and overcompensation by the sympathetic nervous system.

In patients presenting with post-acute COVID-19 symptoms consideration should be given to other significant diagnoses such as pericarditis, myocarditis, pneumonia and pulmonary embolism. In those with tachycardia, it is also important to out rule thyroid disorder and iron deficiency. An active stand test wherein one measures resting HR and blood pressure after 5 min lying supine and repeats measurements after 3 min of standing should be performed to determine if orthostatic intolerance in the form of tachycardia and/or hypotension is present.

POTS is a debilitating condition that causes your heart to speed up by at least 30 beats per minute after you move from sitting or lying down to standing. This happens when your body’s autonomic nervous system, which should work automatically, fails to control your blood pressure and heart rate to make up for your change in posture.

It doesn’t always happen immediately. It can sometimes take as long as 10 minutes after you stand. You may get dizzy and even faint. POTS aren’t well-known. Many people with the condition report that it took them quite a while to get a diagnosis.

A faulty immune system that mistakenly attacks your body’s tissues (autoimmune response) also seems to play a part in POTS.

Dysautonomia

Dysautonomia refers to a group of medical conditions caused by problems with the autonomic nervous system (ANS). This part of your nervous system controls involuntary body functions like your heartbeat, breathing and digestion. When the ANS doesn’t work as it should, it can cause heart and blood pressure problems, trouble breathing and loss of bladder control.

Dysautonomia, also called autonomic dysfunction or autonomic neuropathy, is relatively common. Worldwide, it affects more than 70 million people. It can be present at birth or appear gradually or suddenly at any age. Dysautonomia can be mild to serious in severity and even fatal (rarely). It affects women and men equally.

Dysautonomia can occur as its own disorder, without the presence of other diseases. This is called primary dysautonomia. It can also occur as a condition of another disease. This is called secondary dysautonomia.

Examples of diseases in which secondary dysautonomia can occur include:

Diabetes.

Parkinson’s disease.

Alzheimer’s disease

Muscular sclerosis.

Rheumatoid arthritis.

Lupus.

Sjogren's syndrome.

Sarcoidosis.

Crohn’s disease, ulcerative colitis.

Celiac disease.

Charcot-Marie-Tooth disease.

Chiari malformation.

Amyloidosis.

Guillain-Barre syndrome.

Ehlers-Danlos syndrome.

Lambert-Eaton syndrome.

Vitamin B and E deficiencies

Human immunodeficiency virus (HIV).

Lyme disease.

Mononucleosis

And now covid 19

What causes dysautonomia?

Dysautonomia happens when the nerves in your ANS (autonomic nervous system), don’t communicate as they should. When your ANS doesn’t send messages or receive messages as it should or the message isn’t clear, you experience a variety of symptoms and medical conditions.

Dysautonomia can affect ANS functions including:

Blood pressure.

Breathing.

Digestion.

Heart rate.

Kidney function.

Pupil dilation and constriction in the eyes.

Sexual function.

Body and skin temperature control.

Are there different types of dysautonomia?

Dysautonomia is a medical term for a group of different conditions that share a common problem – improper functioning of the autonomic nervous system. Some of the conditions caused by primary dysautonomia include: Neurocardiogenic syncope, (NCS)- Postural orthostatic tachycardia syndrome (POTS)- Familial dysautonomia (FD), Multiple system atrophy (MSA)- Pure autonomic failure.

The autonomic nervous system regulates functions we don’t consciously control, such as heart rate, blood pressure, sweating and body temperature. Malfunction in any of these areas can produce symptoms that can be shared by numerous conditions. Doctors who are not familiar with POTS may dismiss these symptoms as lingering effects of COVID-19 — or even psychological symptoms. At the same time, POTS can be very debilitating and requires specific treatment, so an accurate diagnosis is vital.

People with POTS tend to have higher rates of autoimmune markers like those from thyroid disease, rheumatoid arthritis, and celiac disease. They also have signs of inflammation, including in the heart. COVID-19 may also be a cause of this autoimmune response, though more study is needed. preliminary research from Vanderbilt University that found POTS s here are various forms of POTS. Symptoms get worse after meals rich in carbohydrates.

Here are various forms of POTS. The most common are:

Neuropathic POTS: Peripheral denervation (loss of nerve supply) leads to poor blood vessel muscles, especially in the legs and core body.

Hyperadrenergic POTS: Overactivity of the sympathetic nervous system.

Low blood volume POTS: Reduced blood volume can lead to POTS. Low blood volume can cause similar symptoms that may overlap in neuropathic and hyperadrenergic POTS.

Medication, physical therapy, diet can all bring relief

research suggests that "eating small meals throughout the day, and following a low-carb diet, low in refined-grains and sweets could be beneficial, as a complementary approach. It's been known among POTS patients that eating high-carb meals can make you feel worse.

At this point, there is no one standard approach to post-COVID patients with POTS-like symptoms, and treatment should be personalized, based on the diagnosis. “If POTS is confirmed, we generally start aggressive hydration, dietary modifications and certain medications. Eventually, physical therapy is key, but it often takes months before patients respond to treatment sufficiently to be ready for a physical therapy regimen.

Non-pharmacological interventions for treatment of POTS include consumption of 2–3 L of water per day and 10–12 g/day of sodium, lower limb compression stockings and regular and progressive exercise. POTS is a debilitating condition that causes your heart to speed up by at least 30 beats per minute after you move from sitting or lying down to standing. This happens when your body’s autonomic nervous system, which should work automatically, fails to control your blood pressure and heart rate to make up for your change in posture.

In the short-term, if you feel lightheaded or dizzy, sit or lie down right away. When you feel well enough to get up, do it slowly and carefully to give your body a chance to adjust. Ask for help if you need it. Treatment will depend on the nature of your symptoms, age, and general health. Your health care team may suggest that you:

Drink plenty of water- Drink a bottle of water in 1-2 minutes before getting out of bed.

Tighten and relax leg muscles before standing

Sit when possible

Avoid bending over

Get more salt in your diet

Use compression stockings to keep fluid from pooling in your legs

In addition, your doctor could prescribe different medications to fit your symptoms like:

Beta-blockers or calcium channel blockers to lower heart rate

ivabradine

Fludrocortisone or midodrine to help with blood pressure

SSRIs and SNRIs

Anxiety medications

Supplemental vitamins

Medications (including some over-the-counter) for headache or nerve pain

Sleeping with your head raised in your bed (about 6 to 10 inches higher than your body).

Vitassium® is a medical food specifically formulated to provide sodium and potassium for the clinical dietary management for patients with autonomic dysfunction including Postural Orthostatic Tachycardia Syndrome (POTS), Ehlers Danlos Syndrome (EDS), Addison's Disease, Cystic Fibrosis (CF), and Vasovagal Syncope, when increased plasma volume has been shown to be beneficial. Vitassium helps to maintain electrolyte levels, to support healthy blood pressure, and to reduce fatigue and dizziness due to low blood pressure. Contains potassium to assist in regulating the balance of water between plasma (blood) and within the cell.

One mainstay of pharmacological treatment for POTS is beta-blocker therapy to lower the orthostatic tachycardia. Ivabradine is a newer alternative that can slow the sinus node firing rate (by blocking the “funny channel”), without the other potentially negative actions of beta-blockers. It is approved for the treatment of angina in Europe, and more recently in the United States for heart failure in patients with elevated heart rates. Previous nonrandomized case series suggested that ivabradine might help POTS patients, but these studies were not blinded, and improvement in symptoms might have been due to regression to the mean, the placebo effect, or concurrent non-ivabradine therapies.

Some patients are so disabled by POTS that it's hard for them even to stand up. But ivabradine enables them to start moving aground again. Once their exercise tolerance improves, "they no longer need to rely on the drug."

One group with a high incidence of SARS-CoV-2 infection worldwide throughout this pandemic has been healthcare workers. Since our evaluation of these patients, we have seen a number of other young female healthcare workers present with COVID-19 mediated POTS. We believe it is a significantly under-recognized entity. Early recognition and proper management will allow intervention to improve symptoms and earlier return to normality.

The connection between COVID-19 and POTS

A leading theory for why COVID-19 long-haulers develop the syndrome is that "the antibodies produced after COVID may attack the autonomic nervous system.” the onset of POTS following COVID-19 is likely "autoimmune" in nature. "The immune system is confused," causing the misdirected attacks. As a result, the ability of the autonomic nervous system to regulate blood flow is damaged. In POTS patients, the nerve that regulates blood flow isn't working, and not enough blood circulates to the brain.

Research shows that POTS patients tend to have a lower-than-normal level of plasma and red blood cells. Patients with these symptoms might benefit from fludrocortisone, which helps to expand blood volume. Mestinon can help prevent increases in heart rate and improve symptoms, too. This will be prescribed by your health care provider. It's been known among POTS patients that eating high-carb meals can make you feel worse.

COVID-19 has had a massive acute effect on the world’s health and economy. While most people with COVID-19 illness recover completely, others continue to experience chronic and diverse symptoms including autonomic manifestations. Addressing the patient needs of Long-COVID, and especially Long-COVID POTS, will take a significant investment of resources and funding, both for clinical care and research. It is imperative to act during this window of opportunity in hopes of reducing or shortening the burden of symptoms for these patients.



Who is at higher risk of serious complications from COVID-19?

Older individuals and individuals with heart disease, lung disease or diabetes are at an increased risk of serious complications from COVID-19. The CDC has also identified other medical conditions that may increase the risk of complications for individuals of any age.

The COVID-19 pandemic has created a unique research opportunity for physicians interested in POTS. In many patients with POTS, it can be difficult to pin down the cause of the condition. In patients with POTS after COVID-19, the cause is clear, and researchers will be able to compare these patients with those who recovered fully from the virus. There’s hope that this cohort of patients will help further research into treatment for all people suffering from POTS.

Exercise and physical activity

Exercise and physical activity are key to managing POTS. Here are important things to know as you undergo an exercise program such as cardiac rehab, as well as other physical activities. Talk with your healthcare provider for specific instructions on these exercises.

Isometric exercises involve contracting your muscles without actually moving your body. Isometrics squeeze the muscle and push the blood back toward the heart. They are simple to do and can be done lying in bed or seated in a comfortable chair. It's a good idea to do these in bed before getting up to prepare your body for sitting and standing.

Transition slowly with your body. Go from lying to sitting on the edge of the bed. Stay there for several minutes, allowing the body to naturally adjust to the change in position. Once you are standing, pause and wait before walking to allow blood pressure to adjust again. If you feel lightheaded at any point, wait for a few minutes in that position to see if it resolves. If not, then return to the prior position as your body isn't adjusting properly. SLOWLY is the key.

Begin a modest walking program. Count how many steps you can do without inducing symptoms. These steps are your initial baseline. Start with walking once a day and go a little further in time, distance or by adding steps. If you feel good, add a second walk in the day. A simple strategy for counting steps is to do 100- 300 steps per awakening hour during the day. Fitness trackers can monitor steps and distance easily. Every week or every few weeks add more steps to your daily total. Simple yoga with focusing on breathing may help reduce POTS symptoms.


How do I cope emotionally with POTS?

Be open and honest with loved ones and support groups about your diagnosis of POTS. Talk about your fears, hopes, struggles and challenges with the condition. Encourage the people who support you to learn more about POTS.

Get enough sleep and eat well to help manage stress.

Shared medical appointments and POTS support groups (either online or in person) will help reduce the feeling of being alone and different.

Be careful with social media. Be mindful of the accuracy of any particular website’s data. Some POTS patients find comfort in social media. For others, social media can cause unnecessary and excessive stress and worry.

Be very cautious of quick solutions from non-medical sources and people. Quick solutions usually don’t help POTS and can even cause more emotional distress.

We recommend counseling to help you learn to cope with a chronic health condition. Counseling may help to control other co-existing mental health issues that may negatively influence POTS.

Meditate or take even just a few minutes of a time-out to help reduce some of your POTS symptoms.

Emotions can have a significant influence on your daily life and health. Identifying them can be useful if you are talking with a counselor or POTS support group.

COVID-19 has had a massive acute effect on the world’s health and economy. While most people with COVID-19 illness recover completely, others continue to experience chronic and diverse symptoms including autonomic manifestations. Addressing the patient needs of Long-COVID, and especially Long-COVID POTS, will take a significant investment of resources and funding, both for clinical care and research. It is imperative to act during this window of opportunity in hopes of reducing or shortening the burden of symptoms for these patients.

These are some the cited articles from PUBMED, MEDLINE, and other clinical trials websites.

Clin Auton Res . 2021 Jun;31(3):365-368. doi: 10.1007/s10286-021-00798-2. Epub 2021 Mar 19.

Immunol Res . 2021 Apr;69(2):205-211. doi: 10.1007/s12026-021-09185-5. Epub 2021 Mar 30

https://coronavirus.jhu.edu/map.html. Accessed April 14, 2021.

Clin Auton Res . 2021 Jun;31(3):385-394. doi: 10.1007/s10286-021-00803-8. Epub 2021 Apr 16

Cells . 2022 Feb 23;11(5):774. doi: 10.3390/cells11050774

BMJ Case Rep . 2021 Jun 14;14(6):e243585. doi: 10.1136/bcr-2021-243585.

Cureus . 2021 Apr 7;13(4):e14358. doi: 10.7759/cureus.14358.

Case Rep Cardiol . 2021 Aug 18;2021:7809231. doi: 10.1155/2021/7809231. eCollection 2021.

Clin Sci (Lond) . 2014 Feb;126(4):289-96. doi: 10.1042/CS20130222.

J Cardiovasc Dev Dis . 2021 Nov 15;8(11):156. doi: 10.3390/jcdd8110156.

J Basic Clin Physiol Pharmacol . 2021 Mar 12;32(3):247-253. doi: 10.1515/jbcpp-2020-0378.

Eur J Case Rep Intern Med . 2021 Mar 22;8(3):002378. doi: 10.12890/2021_002378. eCollection 2021.

Clin Auton Res . 2020 Oct;30(5):449-451. doi: 10.1007/s10286-020-00727-9. Epub 2020 Sep 3

British Journal of General Practice 2022; 72 (714): 8-9. DOI: https://doi.org/10.3399/bjgp22X718037

https://doi.org/10.3390/medicina58010028

J Innov Card Rhythm Manag . 2020 Nov 15;11(11):4302-4304. doi: 10.19102/icrm.2020.111102. eCollection 2020 Nov.

Clin Auton Res. 2020; 30(6): 571–573. Published online 2020 Sep 24. doi: 10.1007/s10286-020-00733-x

https://doi.org/10.1093/eurheartj/ehac031

https://www.jni-journal.com/article/S0165-5728(21)00311-8/fulltext

https://doi.org/10.1007/s10286-020-00727-9

https://doi.org/10.1007/s12026-021-09185-5

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