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Understanding PoTS th 12 July 2022 12pm BST @Lwnurses #LWN #LearnWithNurses Una O’Connor RGN PGCert MedEd Nurse Educator, Learn With Nurses @unasnewsWhat is PoTS? What is PoTS? Postural orthostatic tachycardia syndrome is an abnormality of the functioning of the autonomic nervous system.Is PoTS new? Sir James Mackenzie – the Soldier’s HeartPhysiology of Upright Posture PoTS Symptom Profile 3 most Altered circulation Raised common Syncope * noradrenaline Visual greying Sweating symptoms Brain fog * Tremulousness Orthostatic headaches Nausea/Vomiting Acrocyanosis Diarrhoea, Exercise intolerance Abdo pain Chest pain Sense of anxiety Lightheadedness Poor sleep Fatigue Fast palpitationsMany symptoms are experienced in the upright position (usually standing) and relieved by lying down. Patients can be very disabled by their symptoms. Fortunately, for many patients, symptoms will improve with lifestyle changes, although some people will require medication. However, some will have symptoms over many years. Many healthcare professionals do not know that PoTS exists and so may not think of it as the diagnosis. Orthostatic Intolerance (OI) Syndromes of OI Symptoms of OI Diagnostic criteria: Patient must experience PoTS symptoms mostly when upright over a period of at least 3 months. A sustained increase in heart rate of greater than 30 beats per minute within 10 minutes of standing. Those aged 12-19 years require an increase of at least 40 beats per minute. These criteria may not apply to those with a low heart rate when resting. There is usually no drop in blood pressure on standing. Active Stand Test v Tilt Table Test The Active Stand Test Head-Up Tilt Table Test The active stand test can be used to diagnose This involves lying on a table that can be PoTS. Under careful supervision, heart rate tilted to an angle of 60 to 70 degrees in a and blood pressure are measured after quiet, dimly lit, temperature-controlled resting lying down, then immediately upon room. Blood pressure and heart rate are recorded in a continuous manner. After a standing and after 2, 5 and 10 minutes. This period of 5 to 20 minutes of lying flat, the test may bring on symptoms of PoTS and table is tilted head up. some people may feel unwell or faint. Indian Pacing and Electrophysiology Journal DEFINITION (HRS 2015 consensus) 1. Frequent symptoms of PoTS on standing 2. Associated increase in HR 30 bpm (40bpm in teens) *persistent 3. No drop in BP (but PoTS and VV can co-exist)Triggers In some cases, PoTS has been reported to have developed after: • An infection such as a viral or bacterial illness. • A life stressor such as pregnancy or surgery. • A traumatic event. • Growth/puberty • Immunisation. However, a link with these potential triggers remains unclear. Co-morbidities: • Hypermobility: EDS, HSD • CFS – up to 28% • Autoimmune – Sjogren’s, Diabetes • Mast cell activation syndrome • Post-viral: glandular fever and now Covid January 2021 – NICE Guidance Clinical diagnosis acceptable for Post COVID Syndrome diagnosis and referral to Post-Covid clinics: ECG / Echo normal Holter-sinus tachycardias Active stand test: Active Stand T est • felt faint, palpitations • 135/82 maximum, no drop • HR increased 76-145bpm Long-Covid and PoTS American Autonomic Society statement: ‘many patients are developing chronic symptoms that have been called Long-COVID. Some of the symptoms and signs include those of postural tachycardia syndrome (POTS)’. Several case reports: Symptoms – lightheaded, palpitations, headaches, fatigue, brain fog • PoTS • Orthostatic hypotension • Orthostatic intolerance – not quite meeting the diagnostic criteria for PoTS or OH Davies et al 2020 found 52% (out of 1680) of those who were able to measure heart rate, self-reported a standing heart rate of greater than 30 beats per minute. It is unclear from the study if this increase was sustained, but it does give us some suggestion of the potential scale of the problem. Case reports describing PoTS and orthostatic intolerance (symptoms worse when upright) after Covid infections (Miglis et al 2020, Kanjwal et al 2020, Dani et al 2021). PoTS specialists: potentially affected patients are being referred to their clinics, but they have not yet had an opportunity to fully assess patients or publish journal papers due to long waiting lists for their clinics and lack of access to tilt table testing.Common Misdiagnosis 50% psychiatric - Anxiety - Panic disorder - Depression - Hypochondriasis Vasovagal syncope ?CFS/MEwww.potsuk.org In Summary •PoTS is debilitating for most people •PoTS is not rare •Impact of COVID