Article 7: Long COVID and POTS

Intro and Background:

• What does POTS stand for?

• POTS refers to a development of Orthostatic Symptoms associated with:

  • Increase in what?

  • BUT NOT associated with?

• POTS = Postural Orthostatic Tachycardia Syndrome

• Refers to:

  • Increase in HR ≥ 30 (from normal resting HR)

  • BUT NOT associated with orthostatic hypotension. 

Intro and Background:

• What are the 4 mechanisms used to explain POTS:

• Autonomic neuropathy 

• Increased sympathetic tone

• Hypovolemic state

  • With an altered renin-angiotensin-aldosterone system

• Autoimmunity 

Intro and Background:

• POTS is gaining recognition with COVID during what stage?

• What has been noted in more than half of pts with COVID as POST ACUTE SEQUELAE?

• Post Infectious Stage

• Autonomic Dysfunction

Pathophysiology: Normal Orthostatic Response

• When you stand against gravity, how much ml of blood is displaced to where?

• What gets activated to compensate and maintain CO by what 2 things?

• ~ 500-800 ml of blood is displaced to the abdomen and LE 

• ANS; Increasing HR and Peripheral Vasoconstriction 

Pathophysiology: POTS Mechanism

• What are the 4 main POTS Mechanisms?

• Hypovolemia and Deconditioning

• Autoimmunity

• Neuropathy

• Neuroendocrine Dysfunction

POTS Mechanism: Hypovolemia and Reconditioning

• What has been seen in the majority of POTS pts?

• This causes what 2 things?

• Pts with severe deconditioning further exacerbates what?

• Decreased Intravascular Volume

• 2:

  • Reduced Cardiac Venous Return 

  • Initiates Reflex Tachycardia

• Hypovolemic Symptoms

POTS Mechanism: Autoimmunity

• Pts were detected to have what?

  • For what 3 receptors

• These antibodies cause ___ ____ to be (more/less) effective and cause __ __.

• Autoantibodies

  • Adrenergic Receptors

  • Acetylcholine Receptors 

  • Angiotensin 2 Receptors

• Peripheral Vasoconstriction; LESS; Reflex Tachy

POTS Mechanism: Neuropathy

• Half of POTS cases have some form of ___ ____ ____ resulting in  _____.

Small Fiber Neuropathy resulting in Dysautonomia.

POTS Mechanism: Neuroendocrine Dysfunction

• POTS pts have evidence of:

  • Higher levels of: (2)

  • Lower levels of: (2)

• POTS pts have evidence of:

  • Higher levels of:

    • Catecholamines 

    • Angiotensin 2

  • Lower levels of:

    • Plasma Renin 

    • Aldosterone 

Discussion:

• What condition encompasses a variety of sequelae of health conditions?

• These health conditions last for how long AFTER a COVID Infection?

  • Causing what » which leads to what?

• Post COVID Conditions (PCC)

• Four Weeks or More

  • Causing Autonomic Dysfunction >> lead to POTS

Possible Mechanisms of Post COVID POTS:

• What is one of the most likely mechanisms by which COVID triggers production of Autoantibodies?

  • These Autoantibodies are against what 4 things?

• Autoimmunity

  • Autonomic Nerve Fiber 

  • Adrenergic Receptors

  • Acetylcholine Receptors 

  • Angiotensin 2 Receptors

Possible Mechanisms of Post COVID POTS: Neuroinvasive Capabilities of COVID

• Can DIRECTLY invade CNS/ANS via:

• Can INDIRECTLY invade CNS/ANS via:

• Can directly invade

  • CNS/ANS via olfactory nerve and ACE2 receptors in brainstem 

• Can indirectly invade

  • CNS/ANS via enteric NS via GI tract infection 

Possible Mechanisms of Post COVID POTS:

• Brainstem has a major role in regulation of what 3 systems?

• Brainstem damage results in what?

• 3:

  • Cardiovascular System

  • ANS

  • Neurotransmitter Systems

• Dysregulation

Epidemiology:

• Pts diagnosed with POTS are usually…

• Female to Male ratio is what?  

• > 90% of…

• Younger (18-45) and Female

• 6:1

• Females of Childbearing Age

Clinical Presentation:

• Clinical Presentation of POTS consists of what 2 types of symptoms?

• Orthostatic

• Non-Orthostatic Symptoms

Clinical Presentation: Orthostatic

• Results from what 2 things?

• Occurs when pt ____ and relieved when they ____ ____

• 2:

  • Cerebral Perfusion

  • Increased Sympathetic Stimulation

• Stands; Lie Down

Clinical Presentation: Non-Orthostatic

• Does NON ORTHOSTATIC symptoms associated with changes in cerebral perfusion or sympathetic stimulation?

• Non-Orthostatic Symptoms are ____ of individual Positioning

• NAUR

• Independent

Clinical Presentation: Non-Orthostatic

• What are 6 other body symptoms that can be affected?

• Psychological Dysfunction

• Fatigue

• Gastrointestinal Dysfunction

• Cognitive Dysfunction

• Bladder Dysfunction

• Dermatologic Manifestations

Clinical Presentation: Non-Orthostatic

• Psychological Dysfunction:

  • __ is a common symptom seen in POTS

• Fatigue:

  • Can occur at ___

  • Can also be accompanied by orthostatic symptoms with what?

  • Can occur in ___, last how long/

• PD:

  • Anxiety

• F:

  • Rest

  • Low Tolerance for Physical Activity

  • Cycles, Days to Weeks

Clinical Presentation: Non-Orthostatic

• GI Dysfunction:

  • Changes in bowel habits such as what 3?

• Cognitive Dysfunction:

  • Pts can c/o what 2 things?

• GI:

  • Constipation

  • N/V

  • Stomach Pain

• Cog:

  • Brain Fog

  • Mild to Mod Impairment in Cog and Depression

Clinical Presentation: Non-Orthostatic

• Bladder Dysfunction:

  • What is overactive?

• Dermatologic Manifestations:

  • What are the 3 MC skin changes?

• BD:

  • Overactive Bladder

• Derm:

  • Hives

  • Raynauds Phenomenon

  • Livedo Reticularis

Diagnosis:

• What are the 3 basic criteria for diagnosing pts with POTS?

• Symptomatic Orthostatic Tachycardia

• Autonomic Testing

• Laboratory Values

Diagnosis: Symptomatic Orthostatic Tachycardia

• HR elevation:

  • OLDER than 20:

  • YOUNGER than 20:

• POTS:

  • What happens to their BP?

  • Transient increase in HR:

    • Normal:

    • POTS:

• HE elevation:

  • > 20: > 30 bpm about their baseline when standing w/o orthostatic hypotension

  • < 20: > 40 bpm about their baseline when standing w/o orthostatic hypotension

• POTS

  • Remain stable or INCREASE when standing

  • Transient:

    • Normal: 20 sec w/o any symptoms

    • POTS: 30-60 sec and continues to rise during standing

Diagnosis: Autonomic Testing

• What are the 2 types of Autonomic Testing?

• Which of the 2 is the BEST TEST and easiest to perform?

• 2:

  • Tilt Test

  • Sudomotor Test

• Tilt Test

Diagnosis: Tilt Test and Sudomotor Test

• Tilt Test:

  • Pt is diagnosed with POTS if what 3 things occur?

• Sudomotor Test:

  • This test measures what, which is responsible for what?

• Tilt:

  • Abnormal elevated HR

  • Worsening symptoms in an upright position

  • NEGATIVE for OH

• Sudomotor

  • Autonomic Nerves

  • Sweat Regulation

Diagnosis: Laboratory Values

• T/F: Pts suspected of POTS should undergo lab testing to rule out other cause of Orthostatic Intolerance Symptoms 

True

Differentital Dx:

• Due to wide range of symptoms, what 6 other clinical conditions could present similarly and need to be ruled out?

• Orthostatic Hypotension

• Hypovolemia

• Medication Induced Tachycardia

• Inappropriate Sinus Tachycardia

• Reflex Syncope

• Psychological Conditions

Differential Dx: OH and Hypovolemia

• OH:

  • OH is more characteristic of changes in ___

  • POTS is more characteristic of changes in ___

• Hypovolemia:

  • Avoid diagnosing POTS in pts with what?

• OH:

  • BP

  • HR

• Hypo:

  • Acute or Chronic Diagnosis of Dehydration

Differential Dx: Medication Induced Tachycardia and Inappropriate Sinus Tachycardia

• Medication Induced Tachycardia:

  • Several med can induce tachycardia and lead to what?

• Inappropriate Sinus Tachycardia:

  • Defined as having:

    • ____ at rest

    • ____ on average over 24 hrs

  • Contras with POTS d/t ___ being present at baseline and NOT after positional changes.

• MIT:

  • Misdiagnosis of POTS

• IST:

  • Having:

    • > 100 bpm at rest

    • > 90 bpm on average over 24 hrs

  • Tachycardia

Differential Dx: Reflex Syncope and Psychological Changes

• Reflex Syncope:

  • Pts that experience what can display OH symptoms?

• Psychological Conditions:

  • What 2 things can occur in psychiatric conditions such as ____

• RS:

  • Vagsovagal Syncope

• Psych:

  • Increase HR and Palpitations

  • Anxiety

COVID 19 Vaccine Induced POTS:

• What is the best method, safest, most effective against COVID?

• Incidence of POTS is high ___ AFTER COVID 19 Vaccine compared to ___ BEFORE Vaccine

• ndividual with COVID infection has ___ greater chance of being affected by POTS compared to vaccinated individual who get infected with COVID 

• Vaccine

• 90 days AFTER; 90 days BEFORE

• 5x

Management/Tx:

• What are the 2 main ways to manage/treat POTS?

• Nonpharacological

  • Initially

• Pharmacological

  • When symptoms are severe?

Management/Tx: Nonpharmacological Management

• What are the 4 main ways to treat POTS NONpharmacologically?

• Intravascular Volume Expansion by Salt and Water Intake

• Physical Exercise

• Lifestyle Modifications

• Compressive Garments

Nonpharmacological Management: Intravascular Volume Expansion by Salt and Water Intake and Physical Exercise

• Intravascular Volume Expansion by Salt and Water Intake

  • Daily ___ fluid intake up to ____ and Sodium Chloride up to ___- ___

  • If pt cannot tolerate oral fluid, what to give?

• Physical Exercise

  • What type of exercise is recommended?

  • Can exercise in what position if they cannot tolerate upright position

• Intravascular Volume Expansion by Salt and Water Intake

  • Oral; 3 L/day; 8-12g

  • IV bolus 1-2L of Saline

• Physical Exercise

  • Aerobic Exercise

  • Semi Recumbent

Nonpharmacological Management: Lifestyle Modification

• What are the 3 Lifestyle Modifications that can be done to manage/treats POTS?

• Avoid prolonged bed rest and daytime sleeping

• Cognitive behavioral therapy 

• Increase PA of LE to improve venous return

Nonpharmacological Management: Compressive Garments

• When to apply Compressive Garments? (2)

• 2 types of compression devices?

  • Which one is MORE beneficial?

• When?

  • Severe cases NOT responding to initial Nonpharacological tx

  • Started BEFORE starting meds

• 2:

  • Graded Compression Stockings (30-40 mmHg)

  • Abdominal Binder (10 mmHg)

• Better

  • Abdominal Binder

Pharmacological Management:

• For pts with Orthostatic Tachycardia, what medication will be the drug of choice?

• Beta Blockers

Other Drugs Mentioned:

• Ivabradine

• Fludrocortisone

• Midodrine (Alpha Agonist)

• Pyridostigmine

• Droxidopa

• Methylphenidate

• SSRIs

Special Circumstances in POTS Pts:

• Pregnancy:

  • What form of tx is MOST APPROPRIATE?

• POTS Pts Undergoing Sx:

  • __ ___ when they have fluid oral restriction

• Preg:

  • Non Pharmacological

• Sx:

  • IV Bolus

Quiz:

A 29-year-old female presents to physical therapy reporting persistent fatigue, difficulty concentrating, and shortness of breath that began approximately 3 months after a mild COVID-19 infection. She notes that her heart races when she stands up, and she feels dizzy after standing for more than a few minutes. Her resting heart rate is 70 bpm and increases to 115 bpm within 8 minutes of standing. She denies chest pain or fever. 

Based on this presentation, which diagnosis is most likely?

1. Chronic fatigue syndrome, as all symptoms are consistent and there's no need for further work-up

2.  POTS, as her symptom pattern includes orthostatic tachycardia with minimal exertion 

3. Deconditioning following viral illness, with no clear evidence of autonomic dysfunction 

4. Long COVID, as her symptoms are nonspecific and primarily cognitive and respiratory 

1.  POTS, as her symptom pattern includes orthostatic tachycardia with minimal exertion 

Quiz:

T/F: In some studies, Autonomic Dysfunction (post-acute sequelae) has been noted in more than half of patients with COVID-19.

TRUE

Quiz:

When moving to standing, how much blood (mL) is displaced to the abdomen and lower extremities? 

1. 1000mL 

2. 200 to 400mL 

3. 500 to 800mL 

4. 800-1000mL 

1. 500 to 800mL 

Quiz:

Which of the following is the mechanism by which COVID-19 causes POTS? 

1. Hypovolemia and deconditioning 

2. It is not clear which mechanism exactly leads to COVID-19 POTS 

3. Neuropathy 

4. Autoimmunity 

1. It is not clear which mechanism exactly leads to COVID-19 POTS 

Quiz:

You are evaluating a 24-year-old female patient who reports chronic fatigue, anxiety, brain fog, and exercise intolerance. She denies dizziness or palpitations with standing but complains of a rapid heartbeat during prolonged sitting and mild activity. During testing, her heart rate increases by 35 bpm when walking slowly on a treadmill but only increases by 10 bpm upon standing for 10 minutes. 

Which subtype of POTS is most consistent with this presentation?

1. Orthostatic POTS, as the primary diagnostic feature is an elevated heart rate with positional change from supine to standing

2. Non-orthostatic POTS, as symptoms occur without orthostatic HR changes and are triggered by activity or stress

3. Orthostatic hypotension, because the patient's symptoms are relieved when she sits or lies down

4.  Classic POTS, since the symptoms began after viral illness and involve cognitive fatigue 

1. Non-orthostatic POTS, as symptoms occur without orthostatic HR changes and are triggered by activity or stress

Quiz:

Patients (older than 20 years old) suspected of having POTS will have a heart rate elevation > ___ beats/minutes.  

1. 20bpm 

2. 30bpm 

3. 50bpm 

4. 40bpm 

30 bpm