Postural tachycardia syndrome and long COVID: an update, 2022, Kavi

[Andy]

The postural tachycardia syndrome, or PoTS, was named and defined in 1993,1 but is likely synonymous with earlier conditions such as ‘The Soldier’s Heart’, a term coined by Sir James Mackenzie in 1916.2 Affected patients experience an abnormal response to upright posture resulting in multiple symptoms.3

Autonomic dysregulation causes inadequate vasoconstriction when standing, resulting in blood pooling within the splanchnic vasculature and limbs, and consequent reduced venous return to the heart. An excessive compensatory tachycardia and increased plasma noradrenaline levels contribute to symptoms, the commonest of which are fatigue, palpitations, light-headedness, headache, and nausea.3,4 See Table 1 for a list of symptoms. If not adequately treated, PoTS can become a debilitating disorder that can lead to significant disability and impaired quality of life.
....
Exercise intolerance resulting in prolonged post-exercise fatigue is a common symptom of both PoTS and long COVID, and may hinder ability to engage in an exercise regimen.5 The role of physical activity including exercise in severely exercise-intolerant patients remains unclear and should be undertaken with great caution. Physiotherapists and occupational therapists treating patients with long COVID and PoTS should be familiar with managing these conditions.

https://bjgp.org/content/72/714/8

 

[chrisb]

but is likely synonymous with earlier conditions such as ‘The Soldier’s Heart’, a term coined by Sir James Mackenzie in 1916.2

Is that true? It probably doesn't matter, but if this is wrong can other claims be relied on? I thought "soldiers heart" was synonymous with Da Costa's syndrome and that the term was coined shortly after the US Civil War.

 

[chrisb]

The 1916 MacKenzie paper might be of interest to those of a historical disposition The Soldier's Heart (nih.gov)

It is clear from this:

Perhaps the most interesting series of observations in connection with this particular subject are those which have reference to that condition which is known as " the soldier's heart."

that the term "soldiers' heart" was already in use.

It is also interesting to note the comment @p314 of the Wessely, Hotopf and Sharpe 1997 book that:

The best treatments involved some form of graded activity and or exercise - rest was originally tried, but asas Sir Thomas Lewis wrote "rest in bed has been found to be detrimental rather than beneficial (Lewis T. Report on neuro-circulatory asthenia and its management. Military Surgeon. 1918;42:409-26). Sir Thomas Lewis, Sir James MacKenzie, and Sir William Osler all endorsed proposals, soon implemented, that systematic exercise programmes be introduced into all large military hospitals

One wonders whether there were reports of the success of such treatment

 

[chrisb]

If PoTS is to be regarded as similar to MacKenzie's Soldier's Heart one should be aware of this:

4. The most important series in the category of functional disturbances of the circulation is that which includes the

Dr. Ivy Mackenzie?The Soldier's Heart. 211

disorders of psychic origin, and it is to this series that the soldier's heart in all probability belongs. It is a matter of everyday experience that the heart reacts to emotional shocks. Apprehension, fright, anger, and joy, in their more intense forms, produce rapidity of the heart's action, and even palpitation, depending on the constitutional nervous stability of the subject. These phenomena occur in the ordinary course of everyday life, and it is not difficult to understand that the conditions of warfare, ^with their attendant privations, exhaustion, and exposure to emotional storms of the most severe character, are likely to produce in some subjects circulatory disturbances of a grossly abnormal nature. An attempt to deal with this problem in all its manifold bearings would extend beyond the limits of the present study. It may be suggested, however, that the emotional shocks to which the soldier is subjected do not always leave their impression within the field of consciousness, and that many of the symptoms, very real and disturbing in themselves, are in essence of a hysterical and hypochondriacal character. The particular mechanism which involves a circulatory disturbance as the result of emotional shock may not be easy to define in a given case. The close relationship between the emotional life and the sympathetic nervous system is an accepted fact in clinical experience, and the interdependence of the sympathetic nervous system and the internal secretions is a fact which has been established by physiological experiment and clinical evidence. How far these internal secretions play an intermediate role in the production of cardio-vascular disorder is a matter for speculation, and is of little practical importance here. The fact remains that in the case of the soldier the whole cardio-vascular system is in a condition of instability in the disease under review. Concomitant symptoms in most cases suggest the presence of a neurosis, and a comparison of these symptoms with corresponding cases in other walks of life suggest an emotional disturbance as the fons et origo of the disease

 

[rvallee]

Moved from the general long covid thread.

It's good that POTS is starting to get acknowledged but it has been explicitly denied, belittled and discriminated for decades, and will continue to be for the most part until it's put to a stop, still largely put down as "anxiety" in the vast majority of cases.

At which point does anyone start caring for this? Or are people just going to pretend the past does not exist? That the denial and discrimination were not actively and relentlessly pushed, always explicitly dismissing any connection to viral infections? Hell, even the present barely exists here given how some people who "recognize" POTS are still pushing for BS like central sensitization and other constructs invented because immunology was denied as being at all relevant.

Because meanwhile the focus on POTS still leaves dysautonomia in the same spot as before. Everything is made of some arbitrary increase in heart rate and the one symptom of tachycardia and there is still no accurate understanding making its way yet.

And just by itself having been wrong, doing harm, for decades really ought to get people to react. Not even minimal concern over having been blatantly wrong, having added insult to injury for decades? Exactly the same as politics, zero difference. This is why we can't have nice things. Literally.

 

[chrisb]

I have just come across a rather intriguing aspect to the historical aspects of this. As the original paper under discussion points out, during and after the first world war Lewis and Mackenzie described conditions of Soldier's Heart and Effort Syndrome. Within the descriptions there appears to be an early description of PoTs, orthostatic intolerance and orthostatic hypertension. These findings seem not to have been pursued because of the subsequent work of the cardiologist from the Brompton, Paul Wood. He apparently also worked at an Effort Syndrome Unit at Mill Hill. He gave three lectures in 1941 attributing any findings to psychological factors.

In references mentioning his work there seems to be no mention of this rather crucial passage:

Secondly, a psychiatric diagnosis could nearly always be made-e.g., depressive state, anxiety neurosis, hysteria, hypochondriasis, etc. I am not competent to discuss this aspect, which is being ably handled by my colleagues Dr. Aubrey Lewis and Dr. Maxwell Jones, but I shall try to describe the more obvious emotions, misinterpretations, and psychological twists which lie behind the 'somatic manifestations of this syndrome. It is not enough to unearth psychopathology: it is necessary to explain the incapacity for effort
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2162062/pdf/brmedj04096-0007.pdf/?tool=EBI

So a crucial part of this work is down to the Maudsley.

For any with the time to spare the Lewis monograph makes for interesting reading
The soldier's heart and the effort syndrome (archive.org)

 

[Mithriel]

POTS is obviously a problem in ME and longcovid but I worry that it is being taken out of context for us.

In ME, there is a general dysautonomia (if that is the right word) where the homeostatic control in the body is broken and inefficient. In the ME days it was thought that this was due to damaged parts of the brain and we are still seeing work being done on the brain stem for instance.

If there are many different causes of POTS we must be careful that everyone involved knows about the special problems involved with ME.

 

[rvallee]

POTS is obviously a problem in ME and longcovid but I worry that it is being taken out of context for us.

In ME, there is a general dysautonomia (if that is the right word) where the homeostatic control in the body is broken and inefficient. In the ME days it was thought that this was due to damaged parts of the brain and we are still seeing work being done on the brain stem for instance.

If there are many different causes of POTS we must be careful that everyone involved knows about the special problems involved with ME.

Only POTS is being talked about but dysautonomia is at least as common with LC, often because it's not properly tested. It's annoying that it gets left out entirely, but that's probably because strictly applying POTS criteria means you can objectively evaluate the heart rate elevation and ignore everything else.

Which, hey, funny story about that, as a result almost everything else gets left out, it's basically the same as the obsessive focus on fatigue in ME, at the exclusion of everything else. Even when some things are right, there's a whole bunch of silly stuff in the way.

From what I can tell I think it's pretty similar: most pwLC who have dysautonomia don't meet POTS criteria, but they have everything else, and it gets completely neglected. As is tradition. One more way LC is similar to ME.

 

[Mithriel]

In a way, POTS is an artificial construct like thyroid problems, anaemia and diabetes. If you have a certain number in the test you have the disease but if you do not you are considered healthy!

Yet these numbers are just cut off points which are an average from looking at a large number of people, not a careful knowledge of the disease itself. In diabetes, the numbers were set high because you couldn't get health insurance if you had previous diabetes.

The tests are useful but not quite reaching the cut off point does not mean everything in the body is working properly.

 

[rvallee]

Yup, and the main issue is that it's applied as a firm cutoff, and only looking at tachycardia. 1 bpm short = nothing wrong at all. It's an arbitrary implementation problem more than anything, but that's pretty much the case with everything chronic illness so whatever.