POTS ❤️‍🩹

Covid-19 has finally subsided from the forefront of most people's minds. From the 2020 national lockdown and masks to now, another virus that is tested with the flu when someone is sick. However, Covid-19’s lasting effects continue to linger for some people. Post-COVID Conditions (PCC) vary from person to person and cause autonomic dysfunction, leading to a collection of health changes. A chronic condition known as POTS affects 1 to 3 million people in the United States. Patients with POTS have been on the rise since COVID-19, and there is most likely a connection between the two. 

POTS and COVID-19

The majority of patients are women aged 15 to 50 years (but men can have POTS as well). There is a higher risk from pregnancy, physical trauma, surgery, and viral illness, such as Covid-19.

According to PubMed Central [1], COVID-19 can invade the CNS and ANS via the olfactory nerve and the ACE2 receptor in the brainstem. This brainstem has a major role in the regulation do the cardiovascular system, autonomic nervous system, and neurotransmitter systems. Damage to the brainstem results in dysregulation of these systems, resulting in POTS symptoms. Furthermore, COVID-19 infection can cause hypovolemia, decreased cardiac output, and sympathetic nervous system activation, which is seen in POTS patients. Lastly, a spike protein, a direct toxic action of the COVID-19 virus, attached to ACE2 receptors enters the cell and causes multisystem damage, resulting in dysregulation of the RAAS system, producing POTS symptoms as well. 

From PubMed Central [1]

Autonomic dysfunction, of which POTS is an important subset, has been noted in more than half the patients with COVID-19 [1]. The autonomic nervous system controls involuntary functions such as heart rate, breathing, digestion, blood pressure, etc. Postural Orthostatic Tachycardia Syndrome, also known as POTS is an abnormality of the functioning of the autonomic nervous system. POTS causes an increase in heart rate when changing postural position, specifically from sitting or lying down to standing up. 

What is POTS?

Postural: related to the position of your body 

Orthostatic: Related to standing upright 

Tachycardia: A heart rate over 100 beats per minute

Syndrome: A group of symptoms that happen together

Cleveland Clinic [3] and POTS UK [4] explain how POTS affects the body. Normally when standing gravity causes about 10-15% of blood to settle in the lower half of the body. When a healthy person stands up, blood vessels narrow and contract to maintain blood supply to the heart and the brain. Furthermore, the autonomic nervous system releases epinephrine (adrenaline) and norepinephrine to compensate for the lower amount of blood returning to the heart. These hormones typically can cause a slight increase in heartbeat, however, with POTS patients, we see an exponential increase in heart rate. This is because when someone with POTS stands, a larger amount of blood pools in vessels below the heart. The body responds by releasing more norepinephrine and epinephrine to try and cause more squeezing of the blood vessels. POTS patients' vessels don’t respond to these hormones, but the heart responds with the homorone increase. This imbalance causes a variety of symptoms, with some of the most common being: 

• Dizziness 

• Fainting or near fainting 

• Brain fog 

• Heart palpitations 

• Exhaustion/fatigue 

• Nervousness or anxiousness 

• Shortness of breath

• Chest pain 

• Headaches 

• Discoloration in hands and feet 

• Disrupted sleep

Types of POTS

To be diagnosed with POTS patient's heart rate must increase greater than 30 beats per minute when within 10 minutes of going from sitting to standing. Patients can participate in a tilt table test to monitor their heart rate changes to receive a POTS diagnosis. Different subtypes can result in differing results. There are 3 subtypes of POTS:

• Neuropathic POTS happens when peripheral denervation (loss of nerve supply) leads to poor blood vessel muscles. 

• Hyperadrenergic POTS happens when your sympathetic nervous system is overactive.

• Hypovolemic POTS happens from reduced blood volume.

Symptoms and Flare-ups

As people are familiar with POTS poke fun at, patients carry salt packets or salt pills everywhere, but it is absolutely necessary. While there is no POTS preventatives or cure, there are measures that can be taken to alleviate symptoms. Tracking symptoms and taking proactive steps can prevent flare-ups. According to BUOY [5], certain triggers include: 

• Dehydration or low blood volume 

• Prolonged standing 

• Heat exposure 

• Excessive physical exertion 

• Certain medications 

• Alcohol consumption 

• Menstrual cycle changed 

• Lack of sleep or poor sleep quality

While everyone has different reactions, avoiding these situations can prevent the worsening of symptoms. Most important is to find a balance between hydration with electrolytes and salt intake. Proper hydration is crucial and patients should aim to drink 2-3 liters including electrolytes. Intaking 3-10 grams of salt a day can improve symptoms drastically as well. Wearing compression garments, not skipping meals, avoiding standing for long periods of time, and prioritizing rest can improve the overall quality of life. After these lifestyle changes, patients can look into medications as well:

• Beta-blockers can reduce tachycardia 

• Ivabradine can block the channel responsible for the cardiac pacemaker's current

• Fludrocortisone can temporarily expand intravesical volume 

• Midodrine: works as a vasopressor agent 

• Pyridostigmine is a reversible acetylcholinesterase inhibitor 

• Droxidopa acts as a prodrug to the neurotransmitter norepinephrine 

• Methylphenidate is a long-acting alpha agonist that releases catecholamine 

• SSRIs improve the vasoconstriction reflex by stimulating nerve communication 

My experience

I had COVID-19 four times since the start of the pandemic. After my second time testing positive, I felt like I never fully recovered. My memory and general cognition were decreasing, and I would feel hot and sluggish after I ate meals. I originally went to a gastroenterologist, and I was then told it was just acid reflux and sent home. I began to feel out of breath and had waves of dizziness constantly. I went to several doctors and was told it was anxiety, which is very common among POTS patients. After 2 years I was able to get POTS added to my chart and began researching how to manage my symptoms. I started eating smaller meals, drinking more water and electrolytes, and wearing compression socks every day. Maintaining a certain body temperature is very important to me. I will pass out if I get too hot or cold and normally it is too late by the time I realize. However, POTS is so personalized to each individual and everyone's symptoms, causes, and experiences are different. 

A common apple watch message...

 I have found other people with POTS at the University of Delaware and we have a group chat where we talk about all of our symptoms. To anyone else struggling with a health change, continuing to go to doctors and advocate for yourself is so important. Getting multiple opinions is always helpful, and one doctor's answers and conclusions aren’t always the correct answer. Doing your own research and coming to doctors with possible diagnoses isn’t a bad thing either! Don’t ignore your body telling you something is wrong, and take all the measures you can to make yourself feel better despite what other people have to think or say. 

Keeping a diary of your symptoms is helpful for both yourself and your doctors. It can allow you to see patterns and understand your body's needs. I was able to understand my dietary needs and how much temperature changes impacted me. Recording what I eat allowed me to see what foods trigger symptoms. For example, I learned that caffeine will make me pass out, and then took measures to make sure there is no caffeine in any of my drinks. Since POTS is not well-known among doctors, it is common for patients to not receive a diagnosis for years. Being told it’s anxiety, which I experienced as well, is told to people who are experiencing debilitating symptoms. It’s important to raise awareness of POTS as it continues to increase after COVID-19. The correlation between the two continues to be researched, and POTS programs and clinics have opened up for people who are struggling. Continue to raise awareness and wear the ugly compression socks. 

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC10065129/#REF30

[2] https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/covid19-and-pots-is-there-a-link

[3] https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-tachycardia-syndrome-pots

[4] https://www.potsuk.org/about-pots/what-is-pots/

[5] https://justaddbuoy.com/blogs/pots-resources/pots-syndrome-triggers-dos-and-donts?utm_source=google&utm_medium=cpc&utm_campaign=21397997012&utm_content=169963137753&utm_term=&gadid=716260188641&gad_source=1&gclid=CjwKCAjwnPS-BhBxEiwAZjMF0joYLRsI5_ESFsGTs2BLDWvjDOFTjwsP42By67APCKSR9e9D_rUbGRoCV6sQAvD_BwE