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. 2025 May 8;6(7):949-955.
doi: 10.1016/j.hroo.2025.04.011. eCollection 2025 Jul.

Screening for postural orthostatic tachycardia syndrome using 24-hour electrocardiogram recording in patients with long coronavirus disease

David Hupin  1   2 , Vincent Pichot  2 , Magnus Bäck  1   3 , Malin Nygren-Bonnier  4   5 , Ulrika Reistam  1   3 , Michael Runold  1 , Judith Bruchfeld  1 , Caroline Dupré  2 , Antoine Da Costa  6 , Cécile Romeyer  6 , Frédéric Roche  2 , Marcus Ståhlberg  1   3 , Artur Fedorowski  1   3 , Jannike Nickander  7   8
Affiliations

Screening for postural orthostatic tachycardia syndrome using 24-hour electrocardiogram recording in patients with long coronavirus disease

David Hupin et al. Heart Rhythm O2. .

Abstract

Background: Cardiovascular autonomic dysfunction is a major complication in a large proportion of patients with long coronavirus disease (LC). As one of the most typical phenotypes of cardiovascular autonomic dysfunction, postural orthostatic tachycardia syndrome (POTS) is commonly observed as a sequelae of coronavirus disease infection.

Objective: This study aimed to develop and test a 24-hour electrocardiogram (ECG) recording to direct the clinical suspicion toward the diagnosis of POTS.

Methods: Consecutive patients referred to the Karolinska University Hospital in Stockholm from April 2021 to April 2022 were included. Patients with POTS were compared with patients with LC without POTS (verified by active standing tests) and control healthy subjects according to 3 specific analyses based on 24-hour ECG recording: (1) heart rate (HR) spikes of > 30 beats per minute, (2) awakening HR increase, and (3) HR variability (root mean square of successive difference). The control group consisted of healthy subjects from the database of the University Hospital of Saint-Etienne.

Results: A total of 100 patients with LC (mean age, 42.54 ± 10.45 years; 92% women) and 100 healthy subjects (41.40 ± 7.21 years; 96% women) were included. LC POTS (n = 45) was associated with (1) a higher number of HR spikes/h (1.47 ± 0.84 vs 0.68 ± 0.50 and 0.40 ± 0.28/h; P < .01), (2) an abrupt and sustained increase in HR after awakening (P < .05), and (3) a reduction of HR variability: mean root mean square of successive difference of 34.90 ± 12.48 vs 30.47 ± 19.15 and 43.35 ± 21.10 ms (P < .01) compared with patients with LC without POTS (n = 55) and healthy subjects.

Conclusion: A triple analysis of 24-hour ECG recordings could reveal a characteristic POTS signature in LC. More research in other populations is needed to draw any firm conclusions about its generalizability.

Keywords: 24-hour ECG recording; Autonomic dysfunction; Heart rate variability; Long COVID; Postural orthostatic tachycardia syndrome.

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Conflict of interest statement

The authors have no conflicts to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Flowchart. COVID = coronavirus disease; ECG = electrocardiogram; GP = general practitioner; POTS = postural orthostatic tachycardia syndrome.
Figure 2
Figure 2
Analysis of the kinetics of the mean HR surrounding the awakening of (1) patients with long COVID with POTS, (2) patients with long COVID without POTS, and (3) healthy control subjects. COVID = coronavirus disease; HR = heart rate; POTS = postural orthostatic tachycardia syndrome.
See this image and copyright information in PMC

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