Annals Consult Guys - Postural Orthostatic Tachycardia Syndrome
Authors: Geno J. Merli, Howard H. Weitz
Journal: Annals of Internal Medicine (2021)

Web ExclusivesMay 2021Annals Consult Guys - Postural Orthostatic Tachycardia SyndromeFREEGeno J. Merli, MD, Howard H. Weitz, MDGeno J. Merli, MDThomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Search for more papers by this author, Howard H. Weitz, MDThomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/W20-0021 CME/MOC SectionsSupplemental MaterialAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The Annals Consult Guys discuss the tough-to-diagnose and vexing-to-manage case of postural orthostatic tachycardia syndrome with Dr. Tae Chung.For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys. Comments0 CommentsSign In to Submit A Comment The Consult GuysJefferson University2 June 2021 Author's response The Consult Guys appreciate Dr. Bezerra’s comments and observation. We often recommend venous compression stockings for our patients who tolerate them. The use of medications to increase intravascular volume has to be decided upon on a case by case basis given the potential side effects as well as lack of randomized controlled study. Neomi O. ParraNone28 May 2021 Postural Orthostatic Tachycardia First and foremost thank you for this video. I live in Rural NM and I am the only person in my county that is suffering from a rapid heart rate after Covid. I am a post COVID patient. It has been months and I still do not have a definite diagnoses. My Cardiologist has me on beta blockers but my heart rate still increases when I stand up or walk. In addition, I have the dizziness, headaches, and fatigue. This has helped a lot. Respectfully, Neomi O. Parra Herminio Bezerra MDACP member27 May 2021 orthostatic tachycardia Thank you for the discussion about this extremely interesting case. As I was listening to the presentation, some aspects of POTS reminded me of autonomic dysfunction found in patients with long standing DM type 2 but without the orthostatic hypotension component. During the discussion about treatment I started wondering how effective and sustainable increasing PO fluid and salt intake would be. Eventually the increase in fluid and salt intake will reach a steady state and the symptoms will relapse. I wonder if we could treat POTS as we do autonomic dysfunction, with increase effective intravascular fluid volume with external venous compression, compression stockings, with addition of a low dose Fluorinated cortcosteroid. I will await your response. Disclosures: None. The Consult GuysJefferson University25 May 2021 Author's response The Consult Guys appreciate the insight from Dr. Ginsburg. The patient who we presented had no evidence of dehydration and did not have an orthostatic change in blood pressure. The only change in her vital signs was the postural tachycardia. We agree that an increase in dietary salt is an appropriate initial approach to these patients. The Consult GuysJefferson University25 May 2021 Author's response The Consult Guys appreciate Dr. Boris’ comments regarding the diagnostic criteria for pediatric POTS . Jeffrey Boris, MDJeffrey R. Boris, MD LLC20 May 2021 Diagnostic criteria for pediatric POTS Thank you both for doing this summary on POTS. Although you are correct that the accepted diagnostic criteria for pediatric POTS (age 12-19) is a heart rate increase of at least 40 bpm, we published a study that demonstrated that the symptomatology in pediatric patients with a HR increase of 30-39 bpm vs. 40 or greater was no different (Boris JR, et al. Clin Auton Res 2020;30(1):19-28.). This, as well as some other findings, suggests that the HR cutoff threshold for pediatrics may actually be too high. Unfortunately, in the absence of a biomarker, we are stuck with the combination of symptomatology of orthostatic intolerance (which much be chronic) plus sustained increase in heart rate in the first 10' of upright position (either tilt table test or 10' stand) in the absence of orthostatic hypotension. DAVID S GINSBURG MDNorthwestern17 May 2021 Hypovolemia I"ve seen a bunch of these patients, and all had a low CVP (estimated at bedside). Dry mucous membranes are a poor sign of hypovolemia. Also, most had orthostatic hypotension, when standing BP measured every minute for 5 minutes. Note that this patient had symptoms of orthostatic hypotension (dizziness). They generally respond well to increase in dietary salt. Encouraging increased water intake makes no sense, since most will go intracellular. My guess: the renal sodium retention mechanism has too low a set-point. Author, Article and Disclosure InformationAffiliations: Thomas Jefferson University, Philadelphia, Pennsylvania (G.J.M., H.H.W.)Disclosures: Geno J. Merli, MD, and Howard H. Weitz, MD, report that they have no financial relationships or interests to disclose.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics May 2021Volume 174, Issue 5Page: CG1 ePublished: 18 May 2021 Issue Published: May 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...