Post Covid-19 Tachycardia Syndrome

Hi! This post is pretty timely since after a years wait I finally had my tilt table test to confirm the presence of Post-Covid Positional Orthostatic Tachycardia Syndrome.

It discusses 2 recent papers by authors Stahlberg et al about persistent tachycardia (a fast heart rate) following an acute Covid infection.

If you have been following me for a while you will know that I have written extensively on POTS and inappropriate sinus tachycardia and I referenced these posts below. However it's great to see our theories in print and suggest anyone suffering from a persistent tachycardia since acute Covid - whether at rest or when you stand up or walk about give it a read.

Quick highlights:

  • Post-acute covid-19 syndrome is a novel clinical syndrome with symptoms beyond 4-12 weeks after a SARS-CoV-2 infection

  • Tachycardia is commonly reported in these patients and may be considered a distinct phenotype

  • Putative mechanism for tachycardia in this setting include dysautonomia

  • Post-acute covid-19 syndrome patients reporting palpitations should be subjected to basic cardiovascular evaluation (including head-up TILT testing if concomitant orthostatic intolerance)

  • Treatment options include cardiovascular drugs and structured rehabilitation program

In "Long-Haul Post-COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome: The Swedish Experience" JACC Case Report 2021 authors Johansson & Stahlberg et al reported that a sub-group of patients with Post-acute Covid-19 Syndrome (PACS in the USA, Long Covid in the UK) develop Postural Orthostatic Tachycardia Syndrome (POTS) a cardiovascular dysautonomia associated with sinus tachycardia ( a fast heart rate) and intolerance following orthostatic challenge.

  • An orthostatic challenge is when someone goes from lying or sitting to standing up.

  • The "intolerance" symptoms are - dizziness, presyncope (almost fainting), syncope (fainting), nausea, belching, palpitations, chest pain, headache, migraine, coat hanger pain, breathlessness.

POTS is likely not the sole explanation for elevated heart rate post acute Covid and several other conditions may explain tachycardia in Post-acute Covid-19 syndrome, e.g. inappropriate sinus tachycardia, deconditioning, hypoxia, anxiety, sinus node dysfunction, myocarditis/heart failure and persistent fever.

In the recent paper printed in The American Journal Of Medicine "Post-Covid-19 Tachycardia Syndrome: A distinct phenotype of Post-acute Covid-19 Syndrome", August 2021 -

the authors highlight the presence of tachycardia in PACS/ Long Covid by introducing a new label for this phenomenon: Post-covid-19 tachycardia syndrome and argue that this constitutes a phenotype or sub-syndrome in PACS.

Figure 1 - Potential distinctions and overlaps between post covid tachycardia syndrome and other sub-syndromes in post-acute covid-19 syndrome.

Post-Covid-19 Tachycardia Syndrome as a sub-syndrome or phenotype of PACS/Long Covid

PACS/ Long Covid remains a poorly defined clinical syndrome. Typical symptoms include headache, fatigue, dyspnoea and brain fog, but a very extensive list of symptoms reflecting involvement of multiple organs have been reported. Moreover, the type of symptoms reported may differ vastly between individuals with Post-acute Covid-19 syndrome. In addition, symptoms are likely to be caused by several different mechanisms. All of this taken together suggests that Post-acute Covid-19 syndrome should not be considered a single clinical syndrome but rather a uniting term characterized by different sub-syndromes and phenotypes.

The authors report that:

  • Approximately 25-50% of patients at a tertiary post covid multidisciplinary clinic report tachycardia and/or palpitations persisting 12 weeks or longer.

  • Systematic investigations suggest that 9% of Post-acute Covid-19 syndrome patients report palpitations at six months

  • There are case reports describing patients with postural orthostatic tachycardia syndrome associated with Post-acute Covid-19 syndrome.

  • Inappropriate sinus tachycardia can also be triggered by infections and shares some clinical features with postural orthostatic tachycardia syndrome. . Importantly, apart from the evident tachycardia, both these conditions are characterized by other non-specific symptoms such as headache, fatigue, and cognitive impairment.

  • Together this suggests that tachycardia is a common feature in Post-acute Covid-19 syndrome and it may clinically present as postural orthostatic tachycardia syndrome or inappropriate sinus tachycardia.

Proposed cardiovascular assessment in patients with post-Covid-19 tachycardia syndrome

The authors suggest "liberal use of at least basic cardiovascular assessment in patients with Post-acute Covid-19 syndrome to identify patients with post-Covid-19 tachycardia syndrome (and associated postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia)".

  • TEST 1 - A 24-h ambulatory ECG is recommended to detect arrhythmias, assess average heart rate, detect abnormal pulse reactions and link symptoms to heart rate abnormalities.

Figure 2 - Examples of 24h Holter ECG monitoring from patients with post covid tachycardia syndrome due to (A) postural orthostatic tachycardia syndrome and (B) inappropriate sinus tachycardia.This displays two ECGs from patients who meet the criteria of Post-acute Covid-19 syndrome. The first ECG shows short runs of symptomatic sinus tachycardia (marked with orange arrows) and a typical excessive increase in heart rate in the morning when shifting from bedrest to upright body position (green arrow). These are 24-h ECG patterns raising suspicion of postural orthostatic tachycardia syndrome. The second ECG shows an elevated average sinus rate of 93 bpm, which is consistent with inappropriate sinus tachycardia.

Anyone who has seen my stories would have seen these sorts of images time and again from my Garmin Vivosmart 4.0 watch!!

  • TEST 2 - Patients with Holter-ECG findings suggestive of postural orthostatic tachycardia syndrome and/or presenting with symptoms of orthostatic intolerance should optimally perform a head-up TILT test or, at least, an active standing test to confirm the diagnosis. A 30 bpm increase in heart rate within the first ten minutes of head-up TILT or active standing test without concomitant blood pressure drop and with reproduction of symptoms is diagnostic of postural orthostatic tachycardia syndrome. I have a post on how to test for POTS at home - see references.

  • TEST 3 - A transthoracic echocardiogram should be performed to exclude cardiac abnormalities.

  • TEST 4 - Cardiovascular magnetic resonance (CMRI) studies have reported a prevalence of myocarditis ranging from 27-60% in patients recovering from Covid-19. Since peri-myocarditis may cause tachycardia CMRI should be considered in the setting of typical or atypical chest pain, elevated cardiac biomarkers and/or typical ECG changes.

  • TEST 5 - Blood test are also recommended to evaluate extracardiac causes of tachycardia (autoimmune biomarkers, endocrine tests, inflammation biomarkers, autoimmune biomarkers and hemoglobin levels).

  • TEST 6 - Pulmonary pathology is a common source of tachycardia and basic evaluation should also include peripheral oxygen saturation (at rest and during physiological stress such as a six minute walk test), thoracic CT-scan and spirometry.

Possible treatment for Post Covid Tachycardia Syndrome

Current treatment of POTSto stabilise cardiovascular function include:

  • the selective sinus node inhibitor Ivabradine

  • β−blockers

  • compression garments

Other pharmacological options to reduce associated symptoms are

  • midodrine (symptoms of low blood pressure or cerebral hypoperfusion; peripheral blood pooling)

  • pyridostigmine (muscle weakness; associated gastrointestinal dysfunction)

  • modafinil (brain-fog)

A structured, regular and supervised rehabilitation program is also recommended such as swimming or recumbent cycling and muscle strengthening.

Immunomodulation and drugs targeting possible associated mast cell activation syndrome have not been systematically evaluated in postural orthostatic tachycardia syndrome but might be considered ex iuvantibus if the typical clinical manifestation is present.


Post-Covid-19 Tachycardia Syndrome: A distinct phenotype of Post-acute Covid-19 Syndrome

Long-Haul Post-COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome: The Swedish Experience

Myocarditis at 13 months

Testing for POTS at home

Post Covid Inappropriate Sins Tacycardia

POTS - an overview

Could a POTS/Long COVID/ ME/CFS Connection Explain Much?

PS. my partner bought me this badge (photo) for Christmas -hilarious....

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