POTS is the most frequent cardiovascular autonomic disorder following COVID-19 infection or vaccination, 2025, Fabian Leys et al

[Mij]

Abstract

Background
Cardiovascular autonomic disorders (CAD) were described following COVID-19 infection and vaccination, but previous reports were limited in size and follow-up. Here, we aimed to investigate the type and frequency of newly diagnosed and exacerbated CAD following COVID-19 infection or vaccination, and assessed their associated autonomic and non-autonomic complaints, applied treatment, and clinical outcome at last follow-up.

Methods
Medical records of individuals referred to the Innsbruck Dysautonomia Center between March 2020 and March 2023 were reviewed for new onset of orthostatic intolerance, recurrent syncope, OR exacerbation of previously diagnosed CAD within 6 weeks from a passed COVID-19 infection or vaccination.

Results
Following COVID-19 infection (n = 75), 22 (29%) individuals were diagnosed with postural orthostatic tachycardia syndrome (POTS), 12 (16%) with vasovagal syncope (VVS), 1 with delayed and 1 with transient orthostatic hypotension (OH). Following COVID-19 vaccination (n = 26), 11 (42%) POTS, 2 (8%) VVS, and 3 (12%) transient OH cases were newly diagnosed. In half of newly referred individuals (n = 49/101, 49%), the diagnostic workup excluded any CAD. VVS was the most frequently exacerbated CAD (n = 8/19, 42%). Non-pharmacological measures were recommended to all newly diagnosed CAD, with one-third additionally receiving pharmacotherapy. Follow-up was available in 42 (81%) individuals with newly diagnosed CAD, with a symptomatic improvement observed in 26 (62%) cases.

Conclusion
A specialized diagnostic workup is pivotal to diagnose or exclude CAD in individuals with new-onset orthostatic intolerance or recurrent syncope following COVID-19 infection or vaccination. A multimodal treatment approach can achieve a symptomatic improvement in a substantial proportion of affected individuals.
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[SNT Gatchaman]

Medical records of individuals referred to the Innsbruck Dysautonomia Center between March 2020 and March 2023 were reviewed for new onset of orthostatic intolerance (OI), recurrent syncope, OR exacerbation of previously diagnosed CAD within 6 weeks from a passed COVID-19 infection OR COVID-19 vaccination.

In half of newly referred individuals (n = 49/101, 49%), the diagnostic workup excluded any [Cardiovascular Autonomic Disorders].

Assessment consisted of —

CAFT [cardiovascular autonomic function test], 24-h ambulatory BP monitoring (24-h ABPM), and quantitative sudomotor axon reflex test (QSART) were performed at the Innsbruck Dysautonomia Center under standardized conditions

The CAFT battery comprised a head-up tilt and active standing test, as well as the Valsalva maneuver and deep metronomic breathing.

So despite many of the authors being from departments of neurology, they seemed to not evaluate the brain, focusing more on SFN and cardiac and peripheral vascular autonomic function. Workup did not include evaluation of cerebral blood flow. I would imagine that at least some of those "normal" 50% had decreased cerebral blood flow on tilt testing. See eg Cerebral Blood Flow in Orthostatic Intolerance (2025)

Small fiber neuropathy is regarded as one of the potential mechanisms underlying the pathophysiology of POTS, and in our cohort, QSART abnormalities indicating postganglionic small fiber dysfunction occurred with similar frequency in post-COVID and post-vaccination POTS.

The short latency between infection and symptoms onset observed in most cases indicates a direct immune mediated process, and the stronger immune responsiveness of younger individuals may predispose them to POTS development both after COVID-19 infection and vaccination.

In this series, POTS cases showed similar rates of psychiatric comorbidities to non-COVID POTS cohorts, but many were newly diagnosed with psychiatric disorders after COVID-19 infection or vaccination.