Postural orthostatic tachycardia syndrome as a sequela of COVID-19

Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) sur-vivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mecha-nisms of post-COVID-19 POTS are not well understood. Current hy-potheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous sys-tem by SARS-CoV-2. Practitioners should actively assess POTS in pa-tients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or b-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Addition-ally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic spe-cialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysio-logical mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations be-tween COVID-19 and POTS, possible mechanisms, patient assess-ment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.