The Covid-19 Long Haulers + POTS

Most people who get Covid-19 suffer a very unpleasant few days, but recover completely. However as you’ve undoubtedly heard, some, now called long haulers, are taking much longer to recover. These patients are left with residual symptoms (some of which are new in that they didn’t appear during the original infection) that may be less severe than the misery of those first few days, but now just won’t go away.

The most common long-hauler symptoms are fatigue, lightheadedness when standing, shortness of breath, rapid heart rate, brain fog, digestive issues, and cough. In other words, just like Covid, only a little milder.

(The CDC lists other long-term symptoms as well. Click here to review them.)

It was recently found that many of these post-Covid symptoms are occurring because the patient developed a fairly common condition called POTS, which stands for postural orthostatic tachycardia syndrome. In POTS, moving from a prone to a standing position causes lightheadedness, weakness, and an increase in heart rate, among other symptoms. Here’s a POTS explainer.

We already know the Covid-19 virus can affect the brain and nerves, commonly causing brain fog and loss of smell and taste. With POTS, the Covid-19 virus has invaded the autonomic nervous system, which is in charge of operating much of our body without our thinking about it, functions like breathing, digestion, blood pressure, and heart rate.

Well before Covid, a lot of people had POTS, but it was seldom diagnosed. The range of POTS symptoms includes lightheadedness (to the point of fainting), especially when standing, brain fog, fatigue, racing heart, exercise intolerance, headaches, insomnia, shakiness, nausea, abdominal pain, bloating, constipation, diarrhea, and difficulty urinating.

Most POTS patients go from doctor to doctor for years, endlessly told “Your tests are normal” before finally getting a correct diagnosis. This is because although doctors knew about POTS symptoms as early as the 19^th century, it didn’t appear in the medical literature as POTS until 1993.

Diagnosing POTS
If you’re a long hauler or know someone who is, the basic screening test for POTS is actually quite simple. It can be done in your doctor’s office or, if you have a heart rate monitor, at home. The main finding is an increase in heart rate of 30 beats per minute within 10 minutes of rising from a supine position.

Another important finding is having any kind of symptoms when standing that improve when sitting or lying down.

More advanced testing is usually done in the outpatient section of a hospital using a tilt table. You’re strapped onto a specially designed table, your heart rate and blood pressure are continuously monitored as you’re tilted in different positions, and any changes are recorded.

Once the diagnosis is made, POTS (post-Covid or not) is fairly straightforward to treat, using a combination of lifestyle and dietary adjustments, nutritional supplements, and one or more prescription medications.

Treating POTS
Treatment for POTS (whether post-Covid or otherwise) falls into two groups: lifestyle changes and medications/nutritional supplements.

Lifestyle measures are critically important. You must increase both your salt and fluid intake (the salt and fluid expand your blood volume). This is because people with POTS don’t have enough blood circulating, which is why they experience lightheadedness and dizziness.

You’ll also exercise more (starting slowly, like on a recumbent bicycle), use compression socks, and, if you can tolerate it, raise the head of your bed four to six inches. This will decrease the amount of urine you produce during the night and increase the total volume of your circulation in the morning.

If you’re not responding completely to lifestyle measures, your doctor may add a low-dose beta blocker (such as propranolol or metoprolol) that will “tighten up” blood vessels and prevent your heart rate from escalating when you stand up. Other drugs used to treat POTS include midodrine (raises blood pressure) and fludrocortisone/Florinef (which causes fluid retention and raises blood pressure).

Naturopathic doctors recommend using licorice root tea, which acts like fludrocortisone.

We really don’t know why some people develop POTS, though it’s been linked to nerve damage, adrenal stress, chronic low levels of dehydration, and infections like mono, chronic Lyme disease, and now Covid-19.

You can easily see that many of the symptoms listed for POTS are also listed as part of those the Covid long haulers are experiencing.

Well before Covid-19, many POTS researchers felt there was a viral basis to the autonomic dysfunction that manifested itself as POTS. Now that many long haulers are fulfilling the diagnostic criteria for POTS, at least there’s a roadmap for potentially getting better in the treatments covered here.

If you have post-Covid symptoms or the symptoms of POTS and need some help, please schedule a telemed appointment with any of our practitioners: Wendy Ploegstra, Caley Scott, Rachel Gates, Parisa Samsami, Katie McManigal, or me.

Be well,
David Edelberg, MD