Postural orthostatic tachycardia syndrome a common complication of COVID-19
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Key takeaways:
- Postural orthostatic tachycardia syndrome (POTS) can occur in patients who have survived COVID-19.
- Identifying POTS quickly and starting lifestyle and pharmacological interventions is important.
PHILADELPHIA — Postural orthostatic tachycardia syndrome is a common cardiac complication in COVID-19 survivors and research is ongoing as to optimal treatments, a speaker said during the Heart in Diabetes CME Conference.
“[Postural orthostatic tachycardia syndrome] is a very complex multisystemic disease, and ... is a dynamic disease that needs to be continually reassessed, because patients do get better,” Pam R. Taub, MD, FACC, founder and director of the Step Family Cardiac Rehabilitation and Wellness Center and professor of medicine at UC San Diego Health System, said during a presentation. “I can’t tell you the number of patients we catch early that completely return to normal function. It has to do with ... preventing evolution to the chronic fatigue syndrome phenotype.”
Postural orthostatic tachycardia syndrome (POTS) “is defined as a 30-point increase in the heart rate from a lying to a standing position, and it’s very objective criteria,” Taub said. “It’s also associated with decrease in cerebral blood flow, so a lot of the symptoms that patients with POTS have, such as brain fog and cognitive issues, really have a physiologic basis. There is a lot of research we need to do to uncover what is underlying POTS.”
The COVID-19 pandemic has corresponded with “a huge surge in the number of cases of POTS,” which makes it “a great field that is ripe for disruption and innovation,” she said.
For some patients, tachycardia is the main manifestation of POTS, but for others, autoimmune issues predominate, she said.
Some people have a genetic susceptibility to POTS, and then an event, such as a SARS-CoV-2 infection, “brings out this underlying immunologic derangement,” Taub said. “That causes this patient to be less active, which [leads to] more diminished activity including bed rest, and then there’s this cardiovascular deconditioning that occurs, which leads to a horrible cycle of sympathetic overactivation, tachycardia and orthostatic intolerance.”
Diagnosis is performed by looking at heart rate patterns, she said, noting that the pattern for POTS is “an elevation in the heart rate during waking hours, and if you ask the patient what they were doing at that time, they’ll say they were getting up out of their chair ... just minimal activity. Then if another day there is little elevation, they will say they were in bed all day.”
Lifestyle measures such as avoiding large, heavy meals are important, as is pharmacotherapy that can decrease the heart rate, Taub said.
“One of the problems with medications that reduce heart rate is that they can cause patients to be fatigued, so beta-blockers and calcium channel blockers cause fatigue and can also lower blood pressure,” she said. “These patients already have low blood pressure, so those are not very well tolerated. But ivabradine when used in systolic heart failure produces a great decrease in the heart rate without a decrease in blood pressure. So that gave me the idea that this could be an effective drug for patients with POTS. It has its most potent effect when the heart rate is highest. It’s almost as if this is a drug that was engineered for POTS.”
In a trial of ivabradine for POTS, Taub and colleagues found that ivabradine decreased heart rate and norepinephrine levels and conferred improved quality of life compared with placebo.
A treatment plan should also take into account that many of these patients “will have underlying derangements in their autoimmune system that the COVID-19 infection is just unmasking,” she said, noting that investigations into the role of mitochondrial dysfunction, which could explain why untreated POTS sometimes evolves into chronic fatigue syndrome, are ongoing.
“We really need to take orthostatic vitals on all of our patients that are having these symptoms of tachycardia, chest pain or dyspnea,” she said. “It’s really important to identify these patients early, and once we treat them early, we prevent the evolution into chronic fatigue.”
The persistence of autoantibodies may be why some patients get POTS after surviving COVID-19, Taub said, noting another theory is that the virus persists in fat.
In contrast to patients with POTS not related to long COVID, POTS related to long COVID tends to occur in older patients with cardiometabolic comorbidities, she said.
A strategy of time-restricted eating may help, she said, noting that it leads to ketosis, which improves mitochondrial dysfunction and decreases oxidative stress. Preliminary results from a small study indicate that time-restricted eating may improve quality of life and heart rate in this population, she noted.
Another ongoing study is examining efgartigimod (Vyvgart, Argenx) in the post-COVID-19 POTS population, and “the theory is this is a drug that soaks up autoantibodies, and a theory behind post-COVID POTS is the persistence of autoantibodies,” Taub said.
Previous research showed that in patients with POTS, their glucose-dependent insulinotropic polypeptide (GIP) levels rise after eating, which raises the question of whether drugs that modulate GIP such as semaglutide (Wegovy, Novo Nordisk) and tirzepatide (Mounjaro, Eli Lilly) could benefit that population, she said.
In the meantime, “do simple maneuvers to decrease that initial inflammation” in new-onset COVID-19, such as tell the patient to take an anti-inflammatory over-the-counter medication or prescribe nirmatrelvir/ritonavir (Paxlovid, Pfizer) to prevent or mitigate POTS, she said.
References:
- Clinicaltrials.gov. clinicaltrials.gov/ct2/show/NCT05409651. Updated April 7, 2023. Accessed June 13, 2023.
- Clinicaltrials.gov. clinicaltrials.gov/ct2/show/NCT05633407. Updated April 4, 2023. Accessed June 13, 2023.
- Gluckman TJ, et al. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2022.02.003.
- Taub PR, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2020.12.029.
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Taub PR. Session 9 – COVID-19 in the Cardiometabolic Patient. Presented at: Heart in Diabetes CME Conference; June 9-11, 2023; Philadelphia.
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