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Dr Nick Gall - Recognising autonomic dysfunction and testing

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Summary

This upcoming session with Dr. Nickel is a great opportunity for medical professionals to learn about recognizing and testing for autonomic dysfunction, specifically Postural Orthostatic Tachycardia Syndrome (PoTS). He will provide a thorough overview of this syndrome, the symptoms, its prevalence, and key treatments. He will also touch on the diversity of symptoms, ranging from cardiovascular to gastrointestinal issues, as well as associated fatigue, brain fog, and bladder disturbances. Not only that, but he will discuss the diagnosis and recognize the important role of generalists in of PoTS patients, including tips on how to identify the syndrome. Don't miss this chance to better understand and more effectively treat PoTS!

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Learning objectives

  1. Identify the signs and symptoms of autonomic dysfunction, including postural tachycardia syndrome (POTS).
  2. Describe the demographic in which POTS is most likely to occur.
  3. Explore differential diagnoses for patients presenting with symptoms that may be caused by autonomic dysfunction.
  4. Explain the standard of care for autonomic dysfunction, including testing and treatment strategies.
  5. Summarize the impact of Covid-19 on the diagnosis, treatment and management of autonomic dysfunction symptoms.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

okay. And so now, to a very warm welcome to Doctor Nickel, Uh, he's going to be talking us about recognizing automatic autonomic dysfunction on testing for autonomic dysfunction pots. So one moment so managed to find the lights, as you probably noticed. So hopefully that will allow it to present better eso always the thank you very much for introducing me and asking me to present. Um, I forgot the conflicts of interest. But I have no conflicts of interest other than the patron of pots UK and therefore have a great interest in pots and making sure that it's managed properly. So this is very much to talk about parts because this is also a part masterclass. But I hope that this is therefore instructive for those who are interested in in long covitz. So where does pops fit in? Unfortunately, we have a number of autonomic neurologists in the audience who can put me right. But this is a sort of it is rather old slide off the group of, um orthostatic intolerance syndrome. So a problem in the system where blood essentially doesn't get pumped up properly from your legs to your heart, to your brain on over on the right hand side of the very serious autonomic failure conditions that the autonomic neurologist deal with over on this side. So over on the left side of your screens, the fainting, the things that dominates presentations to syncope, clinics and casualty on then pots, which is there in the middle. So a more milder form off disregulation of the autonomic nervous system. So what? He's pots? Well, it's a syndrome, so and that's important. So it's not one disease, so therefore it. It may be different when you talk to different patients, and it may responds differently on tests that you may respond differently to treatments. But in some way it is a failure off some parts of the system to pump blood upward. So that may be an abnormality in blood volume so that just the blood volume is too small. It may be a failure of peripheral basic constriction, so those blood vessels in your legs don't tighten up enough. It may be that the blood is going to the wrong place at the wrong time, so going to your guts and not go into your brain. Although a classical description from patients is it when they wash their hair in the shower. It all goes to their arms and not to their brain while they're showering. Or it may be an abnormality in heart rate response. Or it may be a mixture of all of those to some degree. But it's all about the inefficiency, the system of getting blood upwards. There is a definition on. We've heard some of the definition already. It's was originally defined in 1993. There is guidance. The 2015 Heart Rhythm Society guidance on Essentially the definition is it is a postural tachycardia off more than 30 beats a minute, sustained over 10 minutes without a fall in blood pressure associated with symptoms. Um, which is essentially what that says. So that's the official definition. How do we recognize the patients? Because it's not about just standing the patient up and seeing their heart rate Well, um, it's by symptoms, as we've heard on, they need to be prolonged symptoms. So the official definition requires really six months of symptoms. We can recognize that actually, an awful lot of people will feel Potsie straight after viral illness, but fortunately a lot of it gets better so So there is definitely a syndrome of orthostatic intolerance that occurs after acute illness. But if it is persistent and lasts for more than six months, then it is called the possible tachycardia syndrome. Importantly in the message for the for the generalists out there is that it's actually rather common. Nobody really knows how common it is that it's been estimated. Perhaps about one in 500 patients, one in 500 people will have pots. So that's actually the same incidence is I trusted cardiomyopathy so and for the cardiology interested? Um, most hospitals will have a cardiologists, a clinic who are interested in hypertrophic cardiomyopathy. But I don't think we can say that about parts. It is very much more common in women. On it tends to be younger women. Eso tends to be 15 to 35 is the classical. That doesn't mean that we don't see patients who are older doesn't mean that it can't develop older. But the vast majority of our patients seem to be off this demographic on D. Prior to Cove it it was particularly precipitated by other viral illnesses like glandular fever. But obviously, now we will see a large number of patients coming with Cove it the symptoms over on the right hand side of this slide detail the sort of symptoms but we hear about this comes from a big Internet registry that Dysautonomia International, the system charity in the States, ran so over 4000 patients. And you can see why so many of our patients and managed by and investigated by cardiologists because essentially, our patients present in general with cardiological symptoms chest pain, breakfast, miss palpitations, dizzy spells, blackouts. But there's an awful lot of other associated beaches. The awful lot of other patients or a lot of our patients will get gastrointestinal disturbances. They will get migraines. They will have the mall non specific. Difficult sentence fatigue, brain fog, bladder symptoms. So a wide range of symptoms which are very easily ignored. You can't possibly have a lot of these symptoms. It must be there for a psychological diagnosis until you think that yes, actually, this is if this is an autonomic condition. Actually, you can have all of those symptoms. So a very large range that sentence, not just cardiovascular, which perhaps when we hear about the treatment is important to remember that just giving cardiological treatments then are not necessarily going to make the patient feel 100% better. So but the sort of things that we hear in cardiology we hear the full range of count extensions. We will hear chest pain. Nobody understands the chest pain associated with pots. A lot of it is musculoskeletal on. During the day, we will begin to understand why they may be upper GI, I said. Soft Ajeel dysmotility reflux symptoms. But also there is tightness. There is chest tightness, which sounds a bit like angina, that potentially maybe some theoretical reasons where there might be current artery dysfunction, we don't know, but there's a lot of chest pain that goes around. A lot of our patients describe breathlessness. A lot of patients describe. I feel more breakfast than I should be. Lots of dysfunctional breathing, sighing, your knitting gasping, and we will hear from Charlene later on about dysfunctional breathing and how important that is to what we see. Um, there's lots of ankle swelling. There's also lots of leg discoloration. So this thing called acrocyanosis that we don't quite understand lots of patients will refer to it as pulling. I think that whether it really is too much blood in your legs or whether it's it is being postulated that it may relate to skin ischemia. But you can see particularly with those pictures, um, how legs go purple and red and nodules, often known as corn beef legs by the patients. So lots of lots of ankle swelling and leg discoloration on standing lots of palpitation, some ectopic beats. Lots of patients will describe it topics, but actually, I don't know that prospect. Shins have any more ectopy than anybody else, but there palpitation very much relates to their Sinus tachycardia. That done was alluding to so persistent sense that my heart is just too fast. It's just doing too much loud. It's fast, lots of dizziness. There's lots of different forms of dizziness, lots of faintness. I feel faint when I stand up a small proportion of pots. Patients will lose consciousness. They will progress on a vasovagal event. You don't have to faint toe, have pots. Lots of times, we see people in clinic who have been told you can't have pots because you don't back out or you you do back out there for it can't be pots, but it's all possible. Faintness it relieved by sitting or, more commonly, lying flat. There are many associative beaches, so it is not just a cardiological set of symptoms on. I think that's what we've learned by managing and assessing. And listening to patients that has been mentioned is hearing the vast range of associated symptoms. Eso we recognized very early on with our physiologists noted lots of dysfunctional breathing on various testing that that we'll we'll talk about. There's a huge amounts of dysfunctional breathing in our patients. On Charlie's published on his experience, many patients describe any level of dysmotility sickness vomiting, bloating, constipation, diarrhea, often labeled is I bs in a robber throwaway comment. Oh, it's just IBSD here, but there's an awful lot of symptomatology and lawful lot of distress caused by those got symptoms. Lots of bladder disturbance. Um, I can't go. I can hold my bladder for the whole day. You have to think about going. I'm going Very frequently are your, um, urologist that Kings published a small Siris of our patients, which showed essentially neuropathic bladder's said these bladder's looked like a diabetics bladder, so there are lots of bladder symptoms, they may know ruin their lives particularly. But it's important, and there are simple ways of helping. Most of our patients have migraines. Most of our patients seem to have this tibia, the migraines. So not only do I get migraines some of the time, but everything spinning ever get the DigiTrace dizziness as well as faintness I'm differentiating those because they're called by entirely different pathophysiology is is important because they need different treatments. And, you know, lots of our patients will have very significant in chronic migraine. Obviously, a lot of our patients are they're not necessarily a lot belong Cove. It will be hyper Mobil. Hyper mobility in some way seems to underpinned. This as a lot of joint symptoms was lots of insomnia Guy Leshner and colleagues that guys have published amongst others on the insomnia. We're not too distant from the Hospital for Integrated Medicine and their insomnia clinic. You see, not Saddam patients in some near is a very important center on, but hopefully later on, we will hear about the histamine problems. So when patients have all of these things on, my view is that we need to ask about all this so very much echoing thoughts from earlier saying, We need general physicians you have to be interested in. This is a generalist. This is not a heart rate issue. This is a systemic. So if we got usually a young woman, but not exclusively who's presenting with this group of symptoms? Yes, let's think about how we can investigate them. The definition is all based on heart rate and BP change. So let's do some BP and heart rate measures. This is this comes from a beat beat BP system just to take you around it. The green line is the heart rate, the two red lines and systolic and diastolic Uh, scale is 40 80 120 160 outside. And you can see this patients lying flat for 10 minutes. Their heart rate's 80. Soon as I stand up, BP takes a dead so it drops and comes back up again. Initial orthostatic hypertension or head rush on. Then immediately the heart rate increases. So the heart rate in this patient then increases behind by 40 beats a minute. With also importantly, I you can see that the BP becomes more variable, and it swings up and down every few seconds. These are known, I am told, a smell, a waves on. Perhaps this this is BP. Cycling. Do two Xs adrenaline, it seems on. This is perhaps even a better guide to orthostatic intolerance than the heart rate increased. So a significant heart region. And of course, if you're measuring this with a single BP cuff a reading every few minutes, you're not going to see it. But it's the significant heart rate increase, but particularly the BP variability that we see that is so important. Back Vidic. It cost 25 grands, so you can't buy it. You can't bite off Amazon, so perhaps doing something like this is more practical. So the nasally and test or just an active stand at home? This is a form, but that's we've written, I've written, but you can find others on the Internet. It's basically 10 minutes of lying flat and then 10 minutes a standing with minutely heart rates of the pressures, and you can do it different times of the day, and you can write down your symptoms because, of course, symptoms are most important. So this may be a good thing. We send it out to a lot of patients. Fill this in and let's have a look. It's important that way. Defined it is 30 minutes or it was defined as 30 beats a minute. Do not, however, gets focused on 30 doctor's medical staff. Focus on 30 patients are absolutely obsessed. Going to use a very rude word with 30. Don't don't have a got 30. It was 29 years, I know, but you've taken my diagnosis away from here. I've got 30. Look, I've sent your photograph of it. I'm not interested because it's much, much more than 30 beats a minute. The original publication from Shonda often know 1993 has been used is the definition They studied retrospectively. 16 patients. They didn't know what was wrong with them. They said, This is postural tachycardia or are you unwell? Don't. Doesn't your heart rate go up? So what? What they did was that they define this is more than two standard deviations away from the mean. So they arbitrarily drew a line in the sand and said, 30 30 is not the be all. In the end, all they're not 29. Your mad 30 You've got a disease on over. On the left hand side is a study that sat each raj and colleagues probably when he was at Vanderbilt, did when they were saying, Should you use an active stand? Should use the pill table test. Is there a difference there? Overall conclusion was that you probably didn't need to. You could do either, but they tested all of these patients between 89 o'clock in the morning. They were all fasted. They'd all have their medications stopped. I can guarantee you that most hospitals in the UK you have a tilt service on awful lot dose, but they do not do testing like this. And this was a very specific study, done so that it was inside a scientific environment. So do not get focused that it is just 30 beats a minute, and therefore that is your diagnosis or not. So remember that there's a lot of people who have fainting out there. There's this smaller group of orthostatic intolerance. I feel ill when I stand. Only a small proportion of those will fill that fulfilled the criteria for pots. That doesn't mean that these people that do not feel ill. It does not mean that they are mad, so there is a lot of static intolerance out there. You can see those changes on those that lead to be BP to see that there are abnormalities. Just you just have to remember that so and this has been sort of taken on by the Canadian Cardiovascular Society In their consensus, which is published in 2020 which said Yes, there are people who fulfill criteria for pots. But there are also people who have postural symptoms without tachycardia, so it's more complicated than just 30 beats a minute. So it's all about listening to the patients and hearing this. We have colleagues in the audience who are autonomic neurologists who do their own brand of testing. They are no more right or wrong been. I am. There is no international consensus about what tests to do. This is what I do because I am a cardiologist, so I do cardiological testing. It's actually about recognizing the pattern, so we do lots of tilt table testing that this comes from the international guidelines which basically say that to be honest with nobody really knows what tests to do. We do Holter monitors toe Look for a with me A. But just because we don't see any with me, it doesn't mean that that's where the diagnosis ends. Because actually, when you look at the heart rate variability in the heart rate trends, you confined greatly. Interesting data. These this patient is spending most of their day and 100 beats a minute. Simple. This patient has a very spiky heart rate profile every time they do anything that are red Ghost cast. So actually, the interest of the Holter monitor is not. Yes, it is a bit to make sure we're not missing an arrhythmia and to count those ectopic beats. Um, reassure. But it's about the heart rate trend, so you can learn a great deal on my congrat. See that? But virtually all of the patients that we see will have had a holter clinicals. It's easily accessible in primary care. We doing over lots of county appropriate size tested county pool makes us testing is really difficult to access because it's complicated and it's time consuming. But it was from this that are physiologists, that kings recognized the dysfunctional breathing. It's very interesting. Talking to some of the major units at the Brompton. Hammersmith Thomas is We're also very interested in cardiopulmonary that's testing. It gives us off a lot of information about levels of conditioning, but it also gives us the idea that that so many of our patients have abnormal breathing control. There is recent data to suggest, because we have no idea why, why patients might prevent a late, that it may be with juice, blood supply to the chemo receptors in the karate. It's that drives the dysfunctional breathing. Um, so very interesting review article um, that came out at the end of last year from some cardiovascular physiologists saying, Actually, perhaps pots is a respiratory condition. We looked at our small group of our patients with See, Pet, Why is this relevant? Is relevant because we found that most of our patients were hyperventilating. What was also important with that? Virtually all of our patients weren't deconditioned by standards deconditioning definition. So pots is not a disease off the unfit. It is not lazy girls, as I was accused of treating that an occupational help physicians conference, most patients. But I'm very grateful to them because it's drove me to Big Steve analysis to write this paper. Eso deconditioning is important. Building up fitness is important, but you will not kill the condition by fitness. Select you do some blood tests. Nobody quite knows cortisol. Very important making sure we're not missing Addison's. But I think tobymac sins getting everything right. And actually, we really noticed acted parts patients, you know they need to have their irons B 12 folic acid, vitamin D to be perfect. They notice the difference. They notice every so getting that right. Shane's autonomic function testing way started off 17 18 years ago and shamed it autonomic function testing on on all of our patients. But, you know, I now see 38 39 patients every week of kings, so we can't do that. But it is helpful to do the more detailed autonomic particular, and we see the younger patients who might be hyped know but but also have diabetes. So where were interesting and trying to differentiate? Is this hyper Mobil related this regulation, or is it underlying autonomic fail? So whatever brand of a active you do, they could be very healthy. So course is an abnormality in the neural control of the county of respiratory system. So this is part of the problem and why we bang on about it. And we run conferences like this because it's on abnormality in the nerve control of the heart of a heart problem. It's a nerve problem that presents with heart disease heart symptoms, which makes it difficult, more common in young women. But it's mostly systemic. And obviously we're going to hear from a Leslie about treatments on obviously, we know that a part of long covert his pots. So to mention the case history, Um, obviously we don't know in this case history. Is that how potsie she is? But there are a number of features she's describing breathlessness. Could that be dysfunctional breathing? She's describing palpitations. She's describing chest pain. She's describing lightheadedness. She's describing exercise. Intolerance is my manner. So this this lady needs to be assessed for pots on Do also coming along to the this little bit of the bottom mild asthma. Johnny, I hope, will mention, you know, he's he's He said this. I say this to so many patients. Most of our patients are diagnosed with asthma. Most of our patients don't have asthma, so it's not. And the problem is as we will hear from Leslie onshore propranolol. Part of stigma and great treatments. Not a good idea in asthmatics. So we're immediately cutting down on a large number of the drugs that we can use for our patients if we just give them first throwaway diagnosed. There was also just finally, a little question about transfer factor, I don't know, but there are small few case reports in the literature off postural changes in chance for factor. So they looked at one or two occasions. Lots of patients with Parkinson's where they did transfer factor standing up, abnormal transfer factor lying down normal. So it may be a lung profusion issue. I don't know. It seems to be that difficult to get postural chance for factor. We used to do transfer factor at King's on all of my patients on just kept coming up with abnormalities. They've all got marble to moderately impaired transfer factor. Where does it come from? Sent along to risperidone? Don't know. We've done all the tests. Maybe it's posture, so testing price. You can't do what I do because there isn't enough resource So maybe in primary care, listen the c g blood tests to a simple stand test. Make sure you're not missing respiratory illness and then think, actually, I think you've got pots. Let's do some simple things in the polls clinic. Yes, it's all of those things. It's whatever. If you're if you're a Queen Square, all of the autonomic testing that they do so well enough for our side. The cardiological testing on trying to come up with the diagnosis you want to know more about pox illness? Shameless plug. We have written a textbook. Lots of people in the audience have contributed to this text book. Um, and on that bombshell, Thank you. Thank you so much. Again, like for that comprehensive review on recognizing and then assessing. So what? We've decided to take ricin since we go. So, firstly, just those in the audience if their questions kicking online for those as well. So thank you. I'm Stephanie. Children GP. Lots off patients come in using, um, heart rate monitors attached to watch is or devices that way. And actually, I'm finding it incredibly helpful. Do you have any that you think of better than this on Or do you rely on them for patterns? If nothing else. So curious. Think your thoughts on wearable 10 years? Yes, S O s. Oh, yes, of course. We get an awful lot. Um, I think that the cardia system that you can buy linked into mobile phones and built into the latest Apple Watch is if you can show me an E C g and I can see it and I can see the arrhythmia, then I'm then I'm very interested on day. Could be very helpful. They over call f s. Oh, you know, I'm sure that that in, um, in the States in in California, it was designed to say We need to find a device that looks for a F because that's where the money is. So it's often very much over calls a f on that That could be a problem. Young people saying, I've got a So so show me the CD. Most of the time it's electrical noise. You know, we've had to I get lots of the males. It said that my QRs is broad. Can you explain this now, etcetera, etcetera. Um, I personally find the pulse oximeter the world's most inaccurate device, Doc. It says that my no, no, my oxygen saturations 2. 74% undead, you know, but But also explain it on. You know, I need a nerve agent review in the Pots clinic, and we have a eight month wait because my pulse oximeter says the time the High Popsicle. So So I really, really big pinch of salt with the parts oximeter. What about for heart rate? So I think it's very much a broad Well, so it depends that the heart rate with the pulse ox is very much if it's picking up that the right, you know, a good signal. But then how often is the patient able to give us a full history about that? It's really picking, picking up a good signal. So if you get you're happy with signal, if it's in front of you and that that's very helpful. I think that if you've got broad heart rate information from the Apple Watch or the garment or whatever polar or whatever that says my average heart rate was this. My resting heart rate was 60. My average heart rate now is 80. So well, that's interesting data. I get too many emails with a tiny little blob circled on the Wednesday afternoon. Doc, what is this? This must be an arrhythmia. Explain my own with me. So? So I think a broad idea about heart rate and how it's changed, I think is probably very interesting, I But it is a big pinch of salt. Well, when can I, um, Can I just have to? Well, not just Sorry, not just for the heart rate and the heart rhythm. A lot of these bits of kick now also do BP. So on Greeley don't go anywhere near the watchers for BP is the way to go. You just it really It really doesn't work. Even the patients like it. Bring it in. Don't know that. Stay away. Quite a few questions on this precipitous of the criteria. And how long does the sustained abnormal heart rate need to be with a couple of minutes? Be sufficient, or we again back to the broad picture. When it comes to the specifics, the definition is 10 minutes. So So if we're going to be specific about it, it should be 10 minutes on. But, you know, I you know, so yes, you can You can see on that trace that I showed it flipped up very, very quickly and stayed that so minutes. But we have other people where it gradually drips up, Uh, 10 minutes. Eso I think it's very variable, but we also see people who may have some degree of orthostatic intolerance where it peaks and then it gradually settles down again on so picking up those those ones who are maybe slightly different, we don't know. So I would much prefer that you stand up for 10 minutes and that we look at the data over 10 minutes. Um, but but But again, I mean my I need my own view of the diagnosis of all of this is are you the right sort of person? Do you have the right sort of clinical findings? Have we made sure that we're not missing anything else? Andi, do you get better with the treatments? So actually, I think that it's slightly more complicated and it's a little bit mawr. You know, you can't be quite so specific because again, if you go up to 20 But you feel great on my tablets, then. Actually, I'm I'm very happy. We're probably treating the right thing, Doc. I tried six different drugs, and none of them have made me better. The reasons that drugs don't work in that was in not treating the right thing. Yeah, presenting this a lot of variability. There's a huge amounts of variability and mentioned with Satish, is publication different times a day, worst in the morning. Worse after a meal. Worse at the time of the month, we'll just before worse after excising. This is why colleagues, a Queen Square has such intensive testing of tilt exercise tilts, eat, tilts, etcetera section which you know, Britney Kenbrell that out Very quick Question just on the right. Stand just for the hyper Mobil population here who find it difficult to do a quite stand. How important do you see that is? Oh, do you think it's I mean, it's well, I suppose. Well, you stand for long as you can, but moving around Um, yes, you probably will make a difference. You know, the there is a difference in the physiology between an active stands and the tilts because you are using different muscles so it may reduce the heart rates increase way say, Um, but But then, of course, you might also then say that the heart rate increase might go up because of pain around that. So that's why I think I think thinking about it too much more broad terms rather than very great specifics I think is important. I'm Dr um, Cell, um, retired people now tribunal doctor who sees a lot of people say, Well, two reports on unable to work. I'd like to know what your views are wrong. That natural history and the prognosis. What do you see It getting better? Uh, yes, I know eso so I probably just this, you know, there is no evidence of that kills anybody. It just makes you feel completely crap for years and years and years and years. I think the point about it is I don't think we know because we because we just don't know enough about it. So I don't know what it's doing. Certainly, in a small proportion of patients, it seems to damage small nerve fibers. So So we think the underlying there's in abortion people, there's a small fiber neuropathy. My impression with those is that they that is damage and that is damaged. Full stop. There are There is no doubt that a lot of people can improve and they improve with time, and they improve with what they do in a little bit about what we do. I suspect that the earlier we pick people are often institutes. The sort of the lifestyle things you know is important if we don't get on top of that and people become more and more deconditions and bed bounds the thing that they will become in that, um so the problem, of course, of patients on do some extent with the system is that I can't keep seeing everybody every year for the rest of their lives in my career's, um so a some point they leave and the ones who get better go away and don't tell me they've got better because we just don't see them again. Eso I think there probably is a a lot of people who improve on may get back to some level of functioning and maybe become normal and just say I'm just a bit fainting, but there are people who are very significant effective, but I don't know how we predict those on. I don't know whether if we intervene earlier, whether a lot more of them would get better. So I think it's very difficult. Of course, a lot of our patients are hyper Mobil on. The ability ain't Going Away on that causes lots of joint pains, joint problems and therefore you know they're going to remain ill from that side for a very long period of time. So it's very difficult to predict way we've got one more here. Eso this, a question from something working along, craving from it where there wasn't implying a lot of people with postural hypertension run in pots. Should they still be looking for the multi system involvement? I think we need to define why they got postural hypertension because because, actually, on my original slide of orthostatic intolerance, a postural hypertension is over the other side, That's that's your then started it well, what causes that? Well, either it's acutely I'm bleeding to death or I've got Addison's. Most of the time it might be. I know older patients whose autonomic nervous system is dulled by age. Um, a lot of the time it's over treatment. It's doctor's fault because I'm giving you 14 drugs for your heart and more drugs, you know, for sleep and all those sorts of things. So if it's not medical, were then started to think neurogenic orthostatic hypertension. And that's their business. So So, Actually, I think almost if you're finding, oh age, you need to be thinking more seriously and with those sorts of neurological conditions, then yes, they will be launched his systemic because again it's affecting the same part of the system. And some just don't sneak him because it just sort of relate the how you differentiate between pots and inappropriate, you know, you say to make. So when I say tomato, you know, it's it's that yes, that they don't The guidelines are trying to differentiate. Um, I don't know that they're the same. I don't know that they're different if you if you read the guidelines in detail Pots is postural tachycardia that affects young women with a lot of associate. It autonomic sentence. I S t, however, is a Sinus tachycardia that effects young women with a widespread number of autonomic sensor on, you know, chain said, you know, many, many years ago, you know, neurologist diagnosed parts of cardiologists diagnosed. I ST So then they're probably in the end. It's the same condition or or some variation of the same thing. So I treat it inside. Okay. Over to Layla, is it? Yeah. Yes. Thank you. Really enjoyed listening to you. Eso I'm a physiotherapist. Workin. Ask genetics and long covert clinic. So a lot of what you're saying chimes with my experience. Um, if for those of us who perhaps thinking about possibly this is pots, I'm saying, what? What is the most useful thing to for us to have done in terms of tests or investigations when we refer to you to a pulse clinic hum? Um, um, I if you if you'd asked me a year ago, I would have just said, you know, just the fact that you thought about it. Yes, because it because that's the thing. If you don't think about it, you don't make the diagnosis. If you think about it, then we can actually start somewhere. The great difficulty that we've got and I'm sure that it's the same with Queen Square and then the autonomic clinical Kings is that we are so overwhelmed now to get to my clinic. You now have to have all of the test. Um, so we're now saying, until you've done all the blood tests and the echoes and the Holter is in the exercise test on the taps stand test, we're not going to be able to see because what what we found urine coated. I carried on doing clinics throughout Cove. It was that because of the difficulties the local hospitals would refuse to test, so we would have to test the patients. But once they're in my clinic, we have to We're doing it so we would take three years to collect together that information on It's only after three years. Do we finally have a little test results and we can start to treat the patients. Where is if we say it is actually is probably going to be easier for them to do the tests. So So actually, these days we have to get all the tests, and it may be just a simple as you saying to your cardiologist, we need to get a couple and we need to get these tests done, and then you can revert them to make a little salt it out from the But just thinking about the diagnosis. Is that the major leap? Wonderful. Thank you. So you think very