Management of POTS due to Long COVID

Lilian White, MD
Posted on November 4, 2024

Long COVID (also known as post–COVID-19 condition or postacute sequelae of SARS-CoV-2 infection) continues to be actively studied by researchers. It is a syndromic condition that appears to occur in patients following acute COVID infection or vaccination with symptoms persisting beyond 28 days. It is estimated that 10% to 30% of people are affected following acute COVID infection. Risk factors for the development of long COVID include female sex, higher body mass index, smoking, older age, and pre-existing comorbidities. The symptoms of long COVID tend to involve multiple body systems and components of dysautonomia, suggesting the autonomic nervous system and potential autoimmune mechanisms are relevant considerations in the treatment of long COVID.

Forms of cardiac dysautonomia associated with long COVID include postural orthostatic tachycardia syndrome (POTS), orthostatic intolerance, vasovagal reflex susceptibility, and hypotension. POTS affects approximately 30% of highly symptomatic patients with long COVID. Symptoms of POTS and other forms of cardiac dysautonomia include palpitations, orthostatic symptoms, fatigue, brain fog, sleep disturbance, migraine, and muscle weakness, among others. Interestingly, symptoms of POTS may be seen at the time of acute COVID infection and persist despite resolution of acute COVID or present for the first time months after the initial infection.

POTS can be diagnosed in the family physician’s office; diagnostic criteria are outlined in a Letter to the Editor published in AFP. If suspicion for the diagnosis remains high despite negative in-office testing, tilt-table testing may be considered.

Treatment of POTS has historically focused on maintaining blood pressure through salt supplementation, graded exercise, compression stockings, and medications. In general, a similar treatment approach is recommended for the management of POTS secondary to long COVID. Given that many patients with long COVID experience significant fatigue with exertion (similar to the debilitating fatigue of myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]), some have questioned whether exercise may be contraindicated for POTS in these patients. A 2024 study noted no harm from encouraging exercise in patients with long COVID compared with matched controls. This was a small study of only 62 participants, but it does suggest paced exercise, similar to that recommended for ME/CFS and fibromyalgia, may be considered.

Medications commonly recommended for the treatment of POTS (regardless of the etiology), such as propranolol and midodrine, may also be considered in the treatment of POTS secondary to long COVID. A growing number of studies support the use of low-dose naltrexone, which may reduce neuroinflammation contributing to dysautonomia in patients with long COVID. This is similar to the medication’s use in the treatment of fibromyalgia.

The prognosis of dysautonomia in patients with long COVID is not well understood. A significant number of patients have been shown to spontaneously recover within 12 months; however, because the symptoms may be quite disruptive to work and quality of life, it is worth continuing to study ways to accelerate healing or relief of symptoms in patients with this condition. Additional information on the diagnosis and treatment of long COVID may be found in an AFP article on long COVID.