This article discussed postural orthostatic tachycardia syndrome (POTS), one of the most common autonomic disorders, can present in a number of ways including postural tachycardia, dizziness, orthostatic (position change) intolerance, presyncope (feeling like you may faint, but you do not), and exercise intolerance.

Updated February 14, 2024

Postural orthostatic tachycardia syndrome (POTS), one of the most common autonomic disorders, can present in a number of ways including postural tachycardia, dizziness, orthostatic (position change) intolerance, presyncope (feeling like you may faint, but you do not), and exercise intolerance.

POTS is a common post viral or bacterial infection occurrence after infections such as Epstein-Barr virus and influenza. Now there are indications that long COVID may be associated with new-onset autonomic disorders.

Prescyncope occurs when the amount of blood flowing to your brain temporarily decreases. Symptoms include lightheadedness, sweat, nausea, flushed, weak, fast heartbeat or blurry vision. And syncope is when you actually pass out and later regain consciousness. Some of these factors are harmless, but others can be dangerous, sometimes life-threatening.

What is POTS?

With POTS, the structure of the heart is normal. POTS symptoms arise from a combination of the following:

Lower amount of blood in the circulation
Excessive pooling of blood below the level of the heart when upright
Elevated levels of certain hormones such as epinephrine (also known as adrenaline since it is released by the adrenal glands) and norepinephrine (mainly released by nerves).

When standing, gravity pulls more blood into the lower half of the body. In a healthy person, to ensure that a sufficient amount of blood reaches the brain, the body activates the nervous system, releases hormones that help tighten blood vessels and cause a modest increase in heart rate. This leads to better blood flow to the heart and brain. Once the brain is receiving enough blood and oxygen, these nervous system responses settle back to normal.

With POTS symptoms the blood vessels don't respond efficiently to the signal to tighten. The longer you are upright, the more blood pools in the lower half of your body. This decreased the amount of blood returning to the brain, causing lightheadedness (faintness), brain fog and fatigue. As the nervous system continues to release epinephrine (adrenaline) and its counter part norepinephrine, to tighten the blood vessels, the heart rate increases further. This may cause shakiness, forceful or skipped heartbeats, and chest pain.

POTS is characterized by a sustained heart rate increment of ≥30 beats/min within 10 minutes of standing or head-up tilt. Cardiologic symptoms include chest pain, palpitations, exercise intolerance, and orthostatic (position change) intolerance.

Other symptoms may include fatigue, "brain fog," gastrointestinal issues (abdominal pain, bloating, gastroparesis, and nausea), chronic pain (headache, temperomandibular joint (TMJ) disorder, or fibromyalgia), and sleep abnormalities.

In June, 2021, covidCAREgroup surveyed 750 respondents who reported Long COVID symptoms. We saw that 12 of the 16 most common symptoms in long haulers correlate with possible POTS symptoms, affecting at least 89% of members in the COVID-19 Long Haulers Support group.

A repeat survey in September 2021 revealed that 602 of 940 respondents (64%) were experiencing new onset cardiac issues.

The Physiology of POTS

POTS, affects autonomic (involuntary) nervous system which regulates functions we don't consciously control, such as heart rate, blood pressure, sweating and body temperature. Malfunction in any of these areas can produce symptoms that may be caused by numerous conditions, so it may be difficult to diagnose. Doctors who are not familiar with POTS may dismiss these symptoms as lingering effects of COVID-19 — possibly even psychological symptoms. At the same time, POTS can be very debilitating and requires specific treatment, so an accurate diagnosis is extremely important.

Essentially POTS is an inability to regulate blood volume. Vasomotor function refers to blood vessel actions that change the vessel diameter by vasodilation (opening up) and vasoconstriction (narrowing), controlling how much blood flows through them. Vasomotor denervation is when the nerves don't control the vasomotor actions properly, which may be temporary due to inflammation or permanent due to nerve damage.

The vasomotor center is located in an area of the brain called the medulla, which is responsible for central regulation of cardiac electrical activity, myocardial performance, and peripheral vascular tone.

Researchers suspect that vasomotor denervation causes dilation of the blood vessels, affecting the blood flow to the heart. Symptoms are likely related to inadequate blood circulation and overcompensation by the sympathetic (the fight or flight) nervous system.

How is POTS diagnosed?

POTS is diagnosed using either a 10-minute standing test or a head-up tilt table test; occasionally other tests are performed to identify specific characteristics of POTS present in some patients. Most people's POTS symptoms respond to a combination of diet, medications, physical therapy and other treatments.

How does Long COVID fit in?

Long COVID conditions mast cell activation syndrome leads to the overproduction of histamines by the immune system, resulting in inflammation of the nervous system, organs (including the brain) and the vascular system. Learn more about this at: https://www.covidcaregroup.org/blog/understanding-inflammation-and-long-covid

What can you do?

Any cardiac condition needs to be thoroughly checked by a cardiologist or your primary care doctor. Hydration and electrolyte balance is essential to the proper functioning of nerves and you heart, so the dr may order blood work.

People with COVID often present at the emergency room for feeling sick, but font necessarily appear short of breath. Oxygen is essential for brain, nerve snd organ health and healing, so if your oxygen saturation are under 95, you should ask about inhalers, even if you don't feel short of breath. At home work on your breathing through breathwork, singing and stress management. Learn about breathwork here: https://www.covidcaregroup.org/blog/how-breathwork-can-help-with-covid-recovery

To address MCAS and the high histamines causing the inflammation and dysfunction, talk to the dr about H1 & H2 blockers (anti acids and antihistamines). At home you can try a low histamine diet. Learn more about this here: https://www.covidcaregroup.org/blog/how-can-diet-help-with-covid-recovery.

Many people experiencing long COVID (PASC) POTS have recovered with no evidence of heart damage for most under the guidance of their doctors. Some have been put on blood pressure snd cardiac medications, others heal over time, and still more people have found relief in taking charge of their diet, stress and breathing.

Things you can do to help yourself

Minimizing physical & psychological stressors is essential in recovery from Long COVID.

Nutrition: Try to eat protein and fresh vitamin rich foods daily and avoid chemicals, preservatives, sugars, fast foods, prepared foods and high histamine foods.
Don’t skip meals. Your body needs protein, vitamin C, and vitamin D to heal from any injury or illness. A low histamine or low carbohydrate (sugar) diet is recommended by doctors treating Long COVID (PASC), and many people report a reduction in symptoms within 1-3 days of the diet change, including decreases in sneezing, itching or hives, irritable bowel syndrome, body pain, along with a reduction in swelling and inflammation.
Hydration: A minimum of eight 8 oz glasses of plain water daily is recommended.
Avoid drinks with chemical additives. You can easily make a fresh electrolyte drink yourself by adding a dash of mineral rich Epsom salt and a piece a fruit like a raspberry for flavor instead of spending money on commercial drinks like Gatorade that contain chemicals and sit in plastic bottles for long periods of time. Remember that caffeine and alcohol have dehydrating effects.
Sleep hygiene: Getting 7-9 hours of sleep so your body can repair itself. You need at least 4 hours of uninterrupted sleep to get into the restorative phase of sleep.
Avoid stimulating activities after dinner like thrilling movies or books, arguments, negative news or frustrating stimuli.
If you wake up frequently or with a startle, you may be experiencing drops in your oxygen level, which signal your brain to release adrenaline to force you to take a breath. This could be a temporary inflammation issue or more enduring sleep apnea. Ask your doctor for a sleep study to evaluate your need for a CPAP or BiPAP, a machine that pushes air into your lungs when it senses an apneic episode (periods of not breathing).
Stress management: Stress affects every component of your life.
The only thing you can control about stress is your reaction to it. Try to avoid or minimize your exposure to stressful situations: Turn off the news, make family visits that end unpleasantly short, wait for the morning to have intense discussions, let go of things that annoy you but don’t really matter in the big scheme of things, avoid intense conversations or entertainment in the evening.
Exercise within tolerance: Pace yourself and do not push your body to extremes in any way.
For some this may mean seated breathing exercises, walking to the mailbox. Rest when your body says to slow down. Gradually build on your activity endurance as your body cues you to progress. This can be hard to gauge, because when you feel good you naturally do more, but if you do too much you may experience symptom flare ups 1-3 days later as the post exertion inflammation builds. Some people describe this as post exertional malaise, others experience severe recovery set backs.
Breathwork: You can literally stop the fight or flight reaction by taking slow deep breaths.
Deep slow breathing shuts down the adrenaline flow, slows your heart rate, lowers your blood pressure and decreases stress related histamine release. When you do this, your blood reroutes back to your brain and nervous system to allow you to think clearly. It also allows your body to use its energy and oxygen to heal your inflamed nerves and organs.

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Brought to you by covidCAREgroup, connecting the dots of long COVID through education, research &resources.

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