Characterising Postural Orthostatic Tachycardia Syndrome (POTS) triggered by a viral illness compared to concussion or trauma, 2025, Wilson et al

[forestglip]

Characterising Postural Orthostatic Tachycardia Syndrome (POTS) triggered by a viral illness compared to concussion or trauma

Gemma Wilson, Marie-Claire Seeley, Pauline Slater, Dennis H. Lau, Celine Gallagher

[Letter to the editor]

Link (Clinical Autonomic Research) [Paywall]

---

No abstract, and I don't have access to any of the text.

 

[Jonathan Edwards]

Excerpts

Introduction​

...A 2019 cross-sectional study found that of 1933 POTS patients who could associate a trigger with symptom onset, 41% identified viral illness [3]. The link between POTS and viral illness has garnered increased recognition in the wake of the SARS-CoV-2 pandemic, with autonomic dysfunction identified as the main phenotype in those with long COVID [4].

In contrast, POTS triggered by concussion or trauma is less common, estimated at 11.4% in a large POTS paediatric cohort study [5]. In an adult population who could associate a trigger with POTS onset, concussion and accident/trauma accounted for only 4% and 6%, respectively [3]. However, the burden of post-concussion POTS is likely to rise given increasing emergency department (ED) presentations for concussion, estimated at a 5% increase per annum, and the potential for persistent post-concussive symptoms in approximately 30% of these individuals [6, 7]. Concussion likely causes alterations to autonomic nervous system function, with evidence suggesting that concussion causes axonal injury including damage to brainstem structures and pathways that are responsible for regulation of the cerebrovascular and other systems [8, 9].

... Here we aim to determine differences in baseline demographics, symptom burden, quality of life and comorbidities between those with POTS triggered by a viral illness compared to concussion or trauma.

​

 

[Jonathan Edwards]

Excerpts

Methodology​

Patients were identified retrospectively from the Australian POTS Registry, which collects information on individuals 16 years and older with a physician-confirmed diagnosis of POTS. All registry participants who identified a viral, concussion or trauma trigger for the onset of POTS symptoms were included. POTS diagnosis for registry enrolment was determined using international criteria, namely unexplained orthostatic symptoms for a minimum of 3 months, in addition to a sustained heart rate increase of ≥ 30 beats per minute (≥ 40 bpm in adolescents) during a 10-min active stand test or head-up tilt table test, with an absence of orthostatic hypotension (defined as a drop of ≥ 20mmHg systolic or ≥ 10mmHg diastolic blood pressure within the first 3 min of standing) [1, 11].

...

Primary outcomes were differences in HrQOL, as measured by the EuroQol 5-dimensional instrument (EQ-5D-5L), autonomic symptom burden as measured by the Composite Autonomic Symptom Score (COMPASS-31), gastrointestinal symptom burden as measured by the Gastroparesis Cardinal Symptom Index (GCSI), and fatigue as measured by the Fatigue Severity Scale-9 (FSS). Secondary outcomes were differences in demographics including education and employment status, socialisation, age of symptom onset, diagnostic delay, symptom duration, ED attendance prior to diagnosis and common comorbidities. Differences in self-reported historical hypermobility were examined using the Hakim five-point hypermobility questionnaire [12].

...

The EQ-5D-5L tool evaluates health status across five dimensions (mobility, personal care, usual activities, pain/discomfort and anxiety/depression) and includes a visual analogue scale (EQ-VAS) which provides a global health assessment from 0 to 100, where 100 represents ‘full health’. Additionally, an EQ-utility score was generated from the UK Devlin set, between 0 and 1, with 1 representing ‘full health’ [13]. The COMPASS-31 measures autonomic symptom burden across the domains of orthostatic intolerance, secretomotor, vasomotor, gastrointestinal, bladder and pupillomotor function [14]. Although there is no validated cut-off score for discrimination of symptom severity in POTS specifically, a score of > 40 is considered suggestive of severe autonomic dysfunction. The GCSI uses a Likert-scale measure from 0 to 5, and consists of the subscales of post-prandial fullness/early satiety, nausea/vomiting and bloating. A total score of ≥ 2 indicates moderate to severe upper gastrointestinal tract symptoms [15]. The FSS measures fatigue level, with a score of ≥ 36 out of 63 indicating severe fatigue [16].

...

 

[Jonathan Edwards]

Excerpts

Results​

A total of 218 patients were included from 634 registry participants, with 199 identifying a viral trigger for POTS symptom onset, and 19 with onset post-concussion/trauma (Table 1). A total of 48.7% (n=97) of the viral cohort identified a COVID-19 infection as the proximal trigger for symptom onset. The median age of the total cohort was 33 (IQR 16) years, with the majority being white or European (98.2%). There were fewer females in the concussion/trauma group than the post-viral group (63.2% vs 89.9%; p = 0.004). ... There were no significant differences in comorbidities across cohorts (Table 1). Generalised joint hypermobility was equally prevalent in both groups, with approximately 60% reporting a five-point hypermobility score of ≥ 2 out of 5, consistent with historical or current joint hypermobility.

Table 1 Baseline characteristics and patient-reported outcome measures
Full size table
Autonomic symptom burden was similarly high in both groups, with no differences within the subdomains of orthostatic intolerance, vasomotor, secretomotor, gastrointestinal (GI), bladder and pupillomotor function (Table 1). HrQOL was severely impacted in both groups, as reflected by both the low EQ-VAS and low EQ-utility scores, with no statistically significant differences between cohorts (Table 1). Likewise, no differences were seen in the FSS and GCSI scores between groups (Table 1).

 

[Jonathan Edwards]

Excerpts

Discussion​

...Our results demonstrate that, compared to post-viral POTS, those with concussion/trauma trigger were more likely to be male and unemployed, and less likely to be tertiary educated. However, we found no significant differences in autonomic symptom burden, fatigue severity, gastrointestinal symptoms or prevalence of joint hypermobility. Patients in both groups reported similarly low HrQOL.

...It could be hypothesised that occupations not requiring tertiary education, such as manual labour, may place individuals at heightened risk of concussion or injuries, which may have influenced our findings.

The high symptom burden displayed across both groups supports previous research demonstrating poor quality of life in those with POTS [10]. The prevalence of joint hypermobility within the overall cohort is consistent with other studies [17, 18], and it remains to be determined whether individuals with hypermobility are at heightened risk of post-concussion syndromes. Given that this study focused on a concussion cohort that had presented specifically for assessment of autonomic symptomology, future research should be directed at exploring autonomic dysfunction in a wider post-concussion population. As autonomic dysfunction may not be routinely assessed in post-concussion clinics, this presents an opportunity for assessment and interventions which may assist in improving functional capacity and quality of life.

The main limitation of this study is the small sample size of our concussion/trauma cohort, ... Given that the onset trigger was patient-reported, there is the potential for selection bias in both cohorts. With almost half of the viral cohort citing COVID-19 as their proximal trigger, future research would benefit from further delineation of viral type and severity.

​