ABSTRACT
Post-coronavirus disease 19 (COVID-19) syndrome has substantial health and economic implications. It is multi-systemic, with prevalent autonomic symptoms. Understanding presentations and potential autonomic causes may help guide treatment strategies and recovery. All patients with a suspected or confirmed history of COVID-19 infection who underwent autonomic testing between May 2020 and October 2021 were reviewed retrospectively. We evaluated 62 patients (20 male, 42 female, mean age of 41.38 +/-11.52). COVID-19 was PCR confirmed in 15 patients (26%), and five (8%) required acute hospital intervention. Most common symptoms included palpitations (81%), lightheadedness/ dizziness (62%), dyspnoea (48%), fatigue (46%), or cognitive symptoms (33%) Autonomic testing showed normal blood pressure responses to pressor stimuli, a mean respiratory sinus arrhythmia of 18.89b/m, and Valsalva ratio of 2.09. Postural tachycardia syndrome (PoTS) was diagnosed in 12 patients, autonomically mediated syncope (AMS) in 11, neurogenic orthostatic hypotension (NOH) in two, and initial orthostatic hypotension (IOH) in seven. Normal supine and upright plasma noradrenaline levels were measured in 34 patients (mean 283.38 pg/ml supine;472.43pg/ml tilted). Autonomic testing was reassuring (PoTS and syncope) in the majority with abnormal testing (n=32, or 52%). Further phenotyping of PoTS to exclude neuropathic pathology may be needed. IOH and OH are important considerations.
ABSTRACT
SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Postural orthostatic tachycardia syndrome (POTS) is one of the most common autonomic disorders (1). POTS is diagnosed by increasing heart rate by 30 bpm on more, within the first 10 minutes of standing, without orthostatic hypotension (2). Associated debilitating symptoms are lightheadedness, fainting, tremor, orthostatic intolerance, and tachycardia (2). Viral infections such as HIV, hepatitis C, mumps, Epstein bar virus, and influenza have been commonly reported with POTS syndrome (3 ). We are presenting a rare case of COVID-19 induced POTS. CASE PRESENTATION: 38-year-old presented to the hospital with the chief complaint of shortness of breath chest tightness. Her past medical history was significant for COVID-19 infection two weeks before presentation. On arrival patient's vitals were within normal limits. Her physical examination was unremarkable. Laboratory investigations, including complete blood count, thyroid function test, and comprehensive metabolic profile, were unremarkable. Chest x-ray, CT angiogram, and echocardiogram were unremarkable for any consolidation, pulmonary embolism, and congestive heart failure. Orthostatic vitals were obtained, showing that the patient's heart rate increased from 90 beats/minute to 140 beats/minute, from supine to standing. This patient was diagnosed with COVID-19 induced POTS, given she was meeting the criteria of POTS and no other reason was found for postural orthostatic tachycardia. She was managed conservatively with hydration, and the patient was also instructed about yoga therapy. She was discharged home with a cardiology follow-up. DISCUSSION: COVID-19 induced POTS is a relatively new entity that most commonly affect female, and the estimated prevalence is around is 17 per 100,000 patients (3). It has been reported that 10% of the patient who tests positive for COVID-19 infection remains unwell beyond three weeks after recovery from the infection (2). For some of those patients, POTS may be the cause of their symptoms. The exact pathophysiology for COVID-19 induced POTS is poorly understood and may includes peripheral neuropathy, baroreceptor dysfunction, hypovolemia, and increased serum norepinephrine (2). Nonpharmacological treatment includes increasing fluid consumption of 2 to 3 L of water per day, lower limb compression stockings, and regular exercise (2). The commonly off-label pharmacological treatment include ivabradine, fludrocortisone, midodrine, and beta-blockers (2). CONCLUSIONS: POTS is a new and under-recognized entity. The clinician should have a high suspicion of POTS syndrome in a patient with a history of recent or remote COVID-19 infection presenting with orthostatic symptoms. Timely diagnosis is essential to prevent the morbidity associated with debilitating symptoms. Reference #1: Blitshteyn S & Whitelaw S. Postural Orthostatic Tachycardia Syndrome (POTS) and Other Autonomic Disorders After COVID-19 Infection: A Case Series of 20 Patients. Immunol Res. 2021;69(2):205-11. Reference #2: Jenna Stephanie O'Sullivan, Andrew Lyne, Carl J Vaughan. COVID-19-Induced Postural Orthostatic Tachycardia Syndrome Treated with Ivabradine. BMJ Case Reports CP. 2021;14(6):e243585. Reference #3: Sujana Reddy, Satvik Reddy, Manish Arora. A Case of Postural Orthostatic Tachycardia Syndrome Secondary to the Messenger RNA COVID-19 Vaccine. Cureus. 2021;13(5). DISCLOSURES: No relevant relationships by Arshan Khan