Postural orthostatic tachycardia syndrome after COVID-19 vaccination

Abstract

Background: There is an association between coronavirus disease 2019 (COVID-19) mRNA vaccination and the incidence or exacerbation of postural orthostatic tachycardia syndrome (POTS).

Objective: The purpose of this study was to characterize patients reporting new or exacerbated POTS after receiving the mRNA COVID-19 vaccine.

Methods: We prospectively collected data from sequential patients in a POTS clinic between July 2021 and June 2022 reporting new or exacerbated POTS symptoms after COVID-19 vaccination. Heart rate variability (HRV) and skin sympathetic nerve activity (SKNA) were compared against those of 24 healthy controls.

Results: Ten patients (6 women and 4 men; age 41.5 ± 7.9 years) met inclusion criteria. Four patients had standing norepinephrine levels > 600 pg/mL. All patients had conditions that could raise POTS risk, including previous COVID-19 infection (N = 4), hypermobile Ehlers-Danlos syndrome (N = 6), mast cell activation syndrome (N = 6), and autoimmune (N = 7), cardiac (N = 7), neurological (N = 6), or gastrointestinal conditions (N = 4). HRV analysis indicated a lower ambulatory root mean square of successive differences (46.19 ±24 ms; P = .042) vs control (72.49 ± 40.8 ms). SKNA showed a reduced mean amplitude (0.97 ± 0.052 μV; P = .011) vs control (1.2 ± 0.31 μV) and burst amplitude (1.67 ± 0.16 μV; P = .018) vs control (4. 3 ± 4.3 μV). After 417.2 ± 131.4 days of follow-up, all patients reported improvement with the usual POTS care, although 2 with COVID-19 reinfection and 1 with small fiber neuropathy did have relapses of POTS symptoms.

Conclusion: All patients with postvaccination POTS had pre-existing conditions. There was no evidence of myocardial injuries or echocardiographic abnormalities. The decreased HRV suggests a sympathetic dominant state. Although all patients improved with guideline-directed care, there is a risk of relapse.

Keywords: COVID-19; Chronic orthostatic intolerance; Dysautonomia; Postural orthostatic tachycardia syndrome; SARS-CoV-2; mRNA Vaccine.

Figure 1

Presenting symptoms. GI = gastrointestinal.

Figure 2

Overview of conditions in patients’ past medical histories documented before vaccination. Number in parentheses indicates the total number of affected patients. When no number is included, the symptom was documented in only 1 patient. CSF = cerebrospinal fluid; POTS = postural orthostatic tachycardia syndrome.

Figure 3

Systematic, tailored postural orthostatic tachycardia syndrome workup and therapy algorithm as adapted from the Heart Rhythm Society Consensus Statement. BP = blood pressure; ECG = electrocardiogram; exam = examination; HRV = heart rate variability; IV = intravenous; PO = per os (by mouth).

Figure 4

Treatments trials since vaccination. Lifestyle changes include avoidance of triggers such as heat exposure and prolonged standing, avoidance of large meals, increased salt and water intake, exercise, and use of compression garments. IVIG = intravenous immunoglobulin.