The list of long-term health problems affecting patients after recovering from COVID-19 continues growing. One of these lesser-known conditions is postural orthostatic tachycardia syndrome (POTS), a disorder of the autonomic nervous system. Reports of POTS have spiked in recent months.
Although treatments for POTS exist, the condition often is missed or misdiagnosed, leading to unnecessary suffering and anxiety for patients. However, given the condition’s recent visibility, frontline providers could gain a new understanding of POTS while also providing patients with a fast, accurate explanation for their symptoms.
What makes POTS so challenging? Pamela Taub, MD, FACC, FASPC, associate clinical professor of medicine at the University of California, San Diego, says the condition is a heterogeneous syndrome in which patients can manifest many different symptoms.
“The hallmark of POTS is an elevation in the heart rate [of about 30 points] that occurs when someone goes from lying to standing,” she explains. “But the problem is that patients don’t walk into the office and tell you that their [heart] rate goes up by 30 points when they stand up. What they tell you is they don’t feel great, they have brain fog, they have fatigue, they can’t concentrate, they have blood pooling in their legs, or their stomach is upset.”
Thus, Taub notes patients with the condition often go from provider to provider for months or even years, frequently leading to frustration and poor life quality, before finally receiving the correct diagnosis. It is a problem that could be corrected if frontline providers were more informed about POTS. “It has to be on your radar,” Taub says. “If you are not thinking about it, then you are not going to do the correct testing to make the diagnosis.”
When a provider suspects POTS, the primary test is simple. Ask the patient to lie flat for three to five minutes and take heart rate and blood pressure readings. Then, ask the patient to stand for another three to five minutes and check heart rate and blood pressure readings again.
If a clinician just takes blood pressure and heart rate readings while the patient is sitting, as is typical, he or she might not recognize the tachycardia that goes along with POTS. “You may see just a normal blood pressure and a normal heart rate,” Taub says.
Consequently, if frontline clinicians suspect POTS could be behind a patient’s symptoms, Taub suggests they take the extra step of recording orthostatic vitals. “That can really help to show you patterns,” she says. “Even if there is not a 30-point increase in the heart rate, maybe there is a 20-point increase when the patient goes from lying to standing, which can tell clinicians that there is some physiology that is abnormal. Just getting the vitals and having that diagnosis on the radar is the first step.”
POTS is more prevalent in women, especially younger patients, and it usually strikes those who are otherwise healthy. Further, POTS often follows a viral infection. This accounts for the surge in cases providers are seeing in patients who have recently experienced COVID-19.
“For many years, we have seen that pattern where someone gets something like the flu or mono. After that infection, they have symptoms of POTS,” Taub shares. “COVID-19 is another viral infection. It is just more common and more prevalent worldwide [right now].”
Taub estimates she has seen about a 50% increase in patients with POTS. Many of these cases involve patients who have battled COVID-19. “The thing about post-COVID POTS is that people are not recognizing it immediately. There is often a little bit of a delay in people getting to myself and other colleagues,” Taub observes. “Usually, [they present] about three months or so after they recover from COVID-19.”
Typically, patients will recognize something is not right and will seek medical attention for their symptoms, but then it will take another three to six months before they make it to a provider with experience in treating POTS.
There are multiple medications that can help patients with POTS. For instance, Taub has published research on the efficacy of ivabradine.1 However, she notes emergency providers may feel more comfortable referring patients to a specialist who can provide ongoing care to make specific treatment decisions.
Nonetheless, providing such patients with a diagnosis, letting them know that there are treatments available, and guiding them to a provider with experience in POTS treatment can go a long way toward providing relief. This is particularly true for patients who have been searching for an explanation for their symptoms for many months, if not years.
Because POTS is such a complex disorder, many types of specialists are experienced in managing different facets of the illness. For example, cardiologists often manage patients with POTS, but neurologists might manage headaches patients experience, gastroenterologists can address gastroparesis or problems with digestion, and allergists can treat some immunologic manifestations. Further, rehabilitation experts can help with any physical limitations or impairments that arise.
- Taub P, Zadourian A, Lo HC, et al. Randomized trial of ivabradine in patients with hyperadrenergic postural orthostatic tachycardia syndrome. J Am Coll Cardiol 2021;77:861-871.