Introduction
There are no established ESC/NICE guidelines for early risk preventive strategies for postural tachycardia syndrome following long COVID-19 infection.1 A lack of early multi-disciplinary input and risk preventive strategies for this population has led to significant cardiovascular implications such as postural tachycardia and syncope, contributing to long-term emotional distress in recent years.1,2
Case presentation
A previously fit 36-year-old woman was admitted to our tertiary centre with a 3-month history of palpitations, chest discomfort and dizziness that were prominent while standing and improved with recumbence. She also described her palpitations, which were sometimes associated with missed beats, and it took longer than expected (at least 10–15 minutes) to settle after postural changes. These symptoms had all significantly impacted on her daily physical activities and caused emotional distress. She gave a history of serious COVID-19 infection requiring hospital admission 4 months previously. She reported that she was treated as having COVID pneumonitis requiring antibiotics, oxygen and steroids but no intensive care admission. Since then, she had noticed frequent episodes of postural palpitations with chest tightness, which had led to her recent admission. On examination, she has normal cardiorespiratory findings and no features of systemic involvement. She has no other significant family and social history with regard to other cardiovascular risk factors.
Initially, she was enrolled into a postural assessment of resting heart rate and blood pressure when she had her symptoms of palpitations. Her resting heart rate was 100 bpm while standing. Interestingly, her resting heart rate returned to normal (54 bpm) after 10 minutes of supine position. Her blood pressure 100/60 while supine and 98/74 when standing, which had ruled out postural hypotension. Following this, an active stand test (tilt table test) was administered on subsequent day. Her electrocardiogram (Fig 1) revealed sinus tachycardia when she had episodes of palpitation but it returned to normal sinus rhythm with heart rate 60 bpm after 10 minutes of recumbent position from standing. All blood investigations, including full blood count, troponins, inflammatory markers and renal profile including electrolytes, revealed normal findings, which had ruled out other differentials.
Discussion
As a whole, these postural assessments (Tables 1 and 2) had met the criteria for definition of postural tachycardia syndrome2 (typical symptoms with significant heart rate increase of >30 beats per minute within 10 minutes of standing and without orthostatic hypotension). To support this, her echocardiogram showed no significant signs of structural heart disease and satisfactory blood investigations. Given her timing of her postural cardiovascular symptoms related to post-COVID-19 infection and criteria being met for postural assessment, she was finally diagnosed as having postural tachycardia syndrome as a cause for long-COVID-19 symptoms.3 Overall, she was advised to increase her fluid intake to 3 litres per day with increased salt intake, to use lower body compression garments and to take non-upright exercise.1 This was followed by early multidisciplinary team (MDT) input, including the recommendation of webinars on living with POTS and psychological counselling.2
Conclusion
It is well-recognised in recent literature that a diagnosis of PoTS post-COVID infection is easily overlooked as it does not associate with structural or arrhythmic heart disease and its specific aetiology is poorly defined apart from autonomic dysregulation.1,3 Therefore, more epidemiology study and detailed prospective research in long-COVID-19 patients are crucial for early recognition of this syndrome and long-term risk prevention.1,2
Source: Khin Kay Kay Kyaw. Long post-COVID-19 postural tachycardia syndrome (PoTS): A novel case. Clinical Medicine Nov 2023, 23 (Suppl 6) 48-49; DOI: 10.7861/clinmed.23-6-s48 https://www.rcpjournals.org/content/clinmedicine/23/Suppl_6/48 (Full text)