Be aware of POTS if you have had even one bout of COVID-19

COVID-19 Induced Postural Orthostatic Tachycardia Syndrome (POTS): A Review

Monitoring Editor: Alexander Muacevic and John R Adler


POTS (Postural Orthostatic Tachycardia Syndrome) is a multisystem disorder characterized by the abnormal autonomic response to an upright posture, causing orthostatic intolerance and excessive tachycardia without hypotension. Recent reports suggest that a significant percentage of COVID-19 survivors develop POTS within 6 to 8 months of infection. Prominent symptoms of POTS include fatigue, orthostatic intolerance, tachycardia, and cognitive impairment. The exact mechanisms of post-COVID-19 POTS are unclear. Still, different hypotheses have been given, including autoantibody production against autonomic nerve fibers, direct toxic effects of SARS-CoV-2, or sympathetic nervous system stimulation secondary to infection. Physicians should have a high suspicion of POTS in COVID-19 survival when presented with symptoms of autonomic dysfunction and should conduct diagnostic tests like the Tilt table and others to confirm it. The management of COVID-19-related POTS requires a comprehensive approach. Most patients respond to initial non-pharmacological options, but when the symptoms become more severe and they do not respond to the non-pharmacological approach, pharmacological options are considered. We have limited understanding and knowledge of post-COVID-19 POTS, and further research is warranted to improve our understanding and formulate a better management plan.

Keywords: postural orthostatic tachycardia syndrome, covid-19 vaccine, pots, sars-cov-2, covid-19

Introduction and background

The COVID-19 pandemic has affected millions since December 2019 []. Long-term effects with adverse outcomes of COVID-19 are increasingly being recognized []. These long-term effects can be seen in patients with mild to severe disease []. Though the SARS-CoV-2 virus primarily affects the respiratory system, it can affect multiple organ systems in the body, including the autonomic system and nervous system []. The harmful effects of COVID-19 on autonomic nervous systems can continue to persist even after the resolution of an acute COVID-19 infection and can be very debilitating []. Effects on the autonomic and nervous systems can adversely affect health and quality of life in patients with a history of COVID-19 infection. One of these manifestations that is increasingly getting recognized is POTS syndrome [].

POTS (Postural Orthostatic Tachycardia Syndrome) refers to the development of orthostatic symptoms associated with an increase in heart rate greater than or equal to 30 (from normal resting heart rate) but not associated with orthostatic hypotension []. The mechanisms proposed to explain POTS include autonomic neuropathy, increased sympathetic tone, a hypovolemic state with an altered renin-angiotensin-aldosterone system, and autoimmunity []. With the reporting of an increasing number of cases, POTS is gaining recognition in patients with COVID-19 in the post-infectious stage []. SARS-CoV-2 can access multiple organ systems through the ACE-2 receptor []. Its pathophysiology is postulated to include virus- or immune-mediated damage to the autonomic nervous system.

Autonomic dysfunction, of which POTS is an important subset, has been noted in more than half the patients with COVID-19 as post-acute sequelae in some studies []. Understanding these critical sequelae of COVID-19 for early diagnosis and effective management is essential. Given the limited literature to date, we aim to comprehensively review current literature and treatment strategies to synthesize the available evidence and enhance understanding of this critical and debilitating condition in patients with POTS after COVID-19 infection.



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