Practice Pointer: Orthostatic tachycardia after covid-19 2023 Espinosa-Gonzalez, Greenhalgh et al

What you need to know

• Tachycardia on standing or minimal exertion may occur after covid-19 and may cause substantial functional impairment
  
  
• When assessing a patient with tachycardia, consider potential causes including autonomic dysfunction
  
  
• Measures to reduce tachycardia can greatly improve function and ability to return to activities and work
  

Patients with long covid—defined by the National Institute for Health and Care Excellence (NICE) as signs and symptoms that persist for more than four weeks (and especially more than 12 weeks) following acute covid-1912—may present in primary care with symptoms of palpitations (tachycardia) triggered by standing or minimal exertion.3 These may be accompanied by dizziness, breathlessness, chest pain, sweating, bloating, fatigue, and other symptoms which may be caused by a dysfunction of the autonomic nervous system (dysautonomia).45678910111213 Patients can find these symptoms debilitating and they can affect function and mood. Limited evidence, variable diagnostic criteria, uncertainty around cause and pathogenesis, and the absence of licensed medications, have all contributed to making this a difficult condition to diagnose and manage. In this practice pointer, we offer an overview of orthostatic tachycardia following covid-19, including a summary of the key steps for diagnosis and management.

Prevalence estimates vary depending on sample and setting, but indicate that about 25% of long covid patients may have dysautonomia14 and 2-14% will develop orthostatic tachycardia (postural orthostatic tachycardia syndrome) six to eight months after infection.341516Box 1 provides more information on these conditions. The assessment and management is summarised in the infographic.

Paywall, https://www.bmj.com/content/380/bmj-2022-073488

 

Have no access to the article so no idea about how the authors deal with the limited evidence there.

Also not able to gauge the usefulness of the added infographic that is free access:

Link to 'infographic' -- free access: https://www.bmj.com/content/380/bmj-2022-073488/infographic



On the 'infographic' no mention of ME/CFS but a box on non-drug treatment includes "Gradual return to exercise if tolerated".

Also, exercise is mentioned as a trigger for PoTS.

Seen here -- thanks to Michael Stingl:

Edited: wording/ clarity

 

It would be a tremendous step forward if physicians became much better acquainted with POTS; how to test and treat it.

 

It would certainly be useful if physicians managed to gather some reliable information on it.

Considering Greenhalgh's history of critical remarks this lukewarm dish of washing-up water comes as a reminder that such people commonly commit the very crimes they criticise.

The treatment section is about as rubbish as you can get, with no evidence base whatever.
GPs will feel self-righteous handing out this stuff to patients as usual.

 

The use of an arbitrary alternative term, orthostatic tachycardia, is weird. There already are orthostatic intolerance, dysautonomia and POTS. It needlessly adds confusion to the issue, which I'm genuinely wondering if it isn't on purpose.

This issue has been known for decades. Patients suffering from this have been mistreated, gaslighted, discriminated and neglected. It was known from day 1 of Long Covid, and very obvious. This weak hot-dog water sauce 3 years into it, genuinely displaying less knowledge than what many patient communities managed in months, is very indicative of how much medicine is continuing to fail at this issue, looking entirely inward and basically continuing to ignore the people this affects.

I don't even understand the point of this paper. There have been many far better published already. These people clearly understand very little of this issue. So why do they think they have anything to teach others when they would fail an intro quiz on this topic?

It even continues to confuse the process for the outcome. Patients don't need to be encouraged to do more and they will resume normal life once the illness is treated or gone. But resuming normal life will not do that. Causality and the damn linear passage of time matter, damnit.

 

(I have followed some of the advice on the infographic and have found it helpful in terms of symptom management, but it isn't treating whatever is the underlying cause.)

Last week I had an in-person appointment with an occupational health physician at my hospital (I got the sense may also be part-time GP). If doctors are said to make the worst patients, I'm sure doctors with ME could raise the bar, particularly if they're able to closely follow the latest research developments. It was over an hour and I resolved to assume the best, and aimed not to get off-piste with theories and conjectures. They had described themselves as "very knowledgeable about ME" and were certainly kind in manner and supportive. On the whole it went as well as I could hope, though it's unfortunate that given the pervasive BPS ideas and outright lying to patients that can occur, it's initially uncertain whether you can de facto trust what a new person is saying vs actually thinking.

Anyhow, there were two notable comments during the consult. One was "I disagree, you definitely don't have ME, because your numbers [tachycardia] do not meet criteria." This was after I had talked about ortho intolerance symptoms and also briefly mentioned my conceptualisation of their cause: esp. relating to reduced cerebral blood flow as pretty robustly demonstrated in publications. I did challenge this as symptoms of orthostatic intolerance and asked what criteria this was based on. No answer, but insistence that ME requires 30+ BPM increase and without this I couldn't possibly have ME. I thought that was strange, but only one of us is living and breathing this stuff.

For reference, my initial POTS diagnosis was made by a cardiologist who has good experience in that area. I was seen very late in the day, when at my best, so didn't quite mount the 30+ BPM elevation at that time. This was recognised as likely under-representing the situation and they were perfectly happy that I qualified for the diagnosis on history, exam, with various rule-out cardiac investigations.

So back to my consult. The physician noted my sports watch and asked me to take a reading. This was sitting, 40 minutes in, during a calm and generally very sensible review and discussion. 67 stable over 20s — a perfectly normal and serviceable HR, even if my prior normal would have been mid 50s or lower. Asked to stand, I gently stood from sitting. It stayed unchanged for about 10 seconds and then went 74 - 83 - 109 - 115 over the next 10s. Hopefully that satisfied that question and I certainly didn't get the response of "how are you doing that?" that I think I recall reading from one of our members previously!

The other comment wasn't problematic as such and of course was very well-meaning, but is a modest example of the whole BPS philosophy and how publications such as this one quoted below encourage medicine to think it's helping by "jollying us along". "Looking at your notes over the last 18 months, you have made great improvements from where you were and I'm very confident that you will recover completely." "I very much appreciate the sentiment and certainly hope that is true, but we can't predict this with any certainty. It can naturally recover, but can also last for decades and even deteriorate." (Good job "ME personality" isn't an official classification criterion, as I might now have qualified!)

 

Tachycardia is not a diagnostic requirement for ME as far as I am aware and in fact I thought there was evidence that OI in ME is most often not POT. Certainly odd.

 

Info about POTS from Dysautonomia International website:


http://www.dysautonomiainternational.org/page.php?ID=30

 

The doc was reciting the criteria for POTS (30 BPM increase). Epic facepalm.

 

CDC website below, includes info on POTS for pwME. While this info does say POTS is common in ME, it does not note a percentage affected in this info:

https://www.cdc.gov/me-cfs/healthca...clinical-course/etiology-pathophysiology.html

From CDC website link:

"Blood pressure or heart rate regulation abnormalities – some people with ME/CFS, particularly adolescents, experience symptoms of orthostatic intolerance. Patients with orthostatic intolerance develop a worsening of symptoms with quiet upright posture and improvement (though not necessarily full resolution) of symptoms with recumbency. Two common forms of orthostatic intolerance experienced by patients with ME/CFS are:

• • Neurally-mediated hypotension (NMH): an abnormality in the regulation of blood pressure during upright posture. NMH is sometimes also referred to as neurocardiogenic syncope, vasodepressor syncope, vaso-vagal syncope, “the fainting reflex”, and delayed orthostatic hypotension.
  • Postural orthostatic tachycardia syndrome (POTS): an abnormality in the regulation of heart rate in which a change from lying to standing causes an abnormal increase in heart rate; the heart is usually structurally normal.

These two conditions can occur together. Notably, not all patients with NMH or POTS have ME/CFS, and not all patients with ME/CFS have NMH or POTS."
(my bolding)

ETA: added for clarity

 

POTS is a (specific) increase in heart rate without a (specific) decrease in blood pressure (orthostatic hypotension). I have noticed the latter criterion is sometimes forgotten about/not known about.

 

Institute of Medicine/National Academy of Medicine diagnostic criteria for ME/CFS:

In addition to a substantial reduction in activity for more than 6 months, PEM, and unrefreshing sleep, either cognitive impairment or orthostatic intolerance are required for a diagnosis:

https://nap.nationalacademies.org/resource/19012/MECFS_ProposedDiagnosticCriteria.jpg

 

When I later re-checked the various classifications, I was already confident I qualified on the more permissive types. I think that the IoM/NAM version might be practically good for general clinician use, although research probably needs to be stricter or clearly delineate sub-types as appropriate to the investigation.

Without cognitive dysfunction (except speech slowing and weak voice initially) I would not qualify on NICE 21. I would be questionably over the line for the "C) Immune, gastro-intestinal and genitourinary impairments" section of ICC, though easily clear A, B and D.

 

I don't think I have POTS (well, not confirmed by a GP as they can't be bothered doing a simple NASA lean test at their practice) but I have documented OI/OH (well, not in the GP's office as my HR and BP gets raised with the stress of the consult and she looks annoyed that I said I do HR and HRV monitoring and tell her what I would like her to do for me).

Never have I heard that the cut off for OI heart rate in ME is 30. Who made this arbitrary judgement? not certain cardiologists that make seriously uninformed comments in local GP magazines? Does not bode well for long covid clinics.

If you had treated POTS you can still have ME, it is a criteria based disorder and there are borderline cases, of course the covid virus may/may not contribute but that is immaterial, covid is a virus and ME is predominantly a post infectious syndrome.

I could pick many holes in the 30+, like elevation of HR from being orthostatically challenged and in PEM, sitting in the wait-room, PEM from going up the stairs in front of the hospital, trying to find a wheelchair, car trip, having to give a history with cognitive impairment when they get that frustrated, time pressured look on their face. That makes my HR quickly go above 100-110 (not 130) and usually with my temper starting to go and rambling history begins and they start considering whether they should have a chat with a liaison psychiatrist Tilt Tests can also be unreliable but I am sure he didn't have one handy.

I can only imagine what he wrote in your Occ Health notes...Of course, you have now convinced me not to recite the latest scientific literature, to a past fellow colleague, when trying to have my ME assessed soon. They don't really appreciate someone that knows more than them and I do not think, despite what they like to tell us in their "cosy" GP language, open to new knowledge. How reassuring for him that you will likely "recover". I am sure he had a kindly manner and warmly sent you on your way but did give you what you need from your employer.

sorry moderators, this reply quote has really gone south. [Fixed. ]

 

yes, thanks, it was meant to be reply to @SNT Gatchaman comments.

 

Yes, that's OI, not POT.

 

Yes, but OI is, if I'm not mistaken an umbrella term. The CDC advises, as per my above posting,#10, that there are two types of orthostatic intolerance common in ME: NMH and POTS.

 

Those are the defined groups. My understanding is that many PWME may have OI for neither reason. OI is not necessarily due to haemodynamic failure.

So rather than being an umbrella term it is a term for a particular symptom. If maybe 20% of ME cases actually have POT then criteria for POT are irrelevant to diagnosis of ME.

 

Greenhalgh on Twitter

"Doctors, if you dismiss someone with orthostatic tachycardia as "just anxious" without taking a full clinical history and properly examining them, you may be part of the problem. We've heard some awful stories. Please: read the paper for advice on what tests to do."

"Not everyone with tachycardia after covid-19 needs extensively investigating. But everyone deserves to have their story heard and documented, and to have a baseline examination."