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All Posts Tagged: hyperadrenergic POTS

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Orthostatic-Hypotension Part 2 Of 6

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Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 2 of a 6 Part Series about Orthostatic-Hypotension

Orthostatic hypotension could be due to impaired autonomic reflexes or intravascular volume depletion (dehydration). Symptoms commonly include dizziness, muscle aches, lightheadedness, fainting, and discomfort in the neck and shoulders, a so-called coat hanger syndrome. Even anginal chest pain can occur with orthostatic hypertension. Other symptoms commonly seen are blurred vision, generalized weakness, cognitive impairment, nausea, palpitations, tremulousness, headaches, and, as mentioned, presyncope and syncope. These symptoms can be incapacitating in patients who have more advanced forms of orthostatic hypotension and can impair them from even walking 10 or 20 feet before they have to sit down or lean against an object. Even more troublesome is that many people who have orthostatic drops have symptoms of autonomic dysfunction in other organs, such as the stomach (gastroparesis), the colon (constipation), the bladder (bladder dysfunction), and in the sweat glands (anhidrosis or the inability to sweat). Some people sweat in patchy distributions and not throughout their whole body and loose body water sweating in certain parts of the body. More worrisome is when orthostatic hypotension is accompanied by movement disorders that can affect balance and gait.

Patients also with postural orthostatic tachycardia may have similar symptoms as described above, as those with postural orthostatic hypotension. In these patients, the blood pressure does not drop, and they usually do not have fainting episodes. Rather, they have racing heart rates, often above 120 and 130 beats per minute. Usually, they are a younger subset of patients, whereas patients over the age of 50 usually will manifest orthostatic hypotension with blood pressure drops. Patients with postural orthostatic tachycardia syndrome, or POTS as it is commonly called, are normally seen in patients in their teens, 20s, and 30s but not commonly after the age of 40

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Orthostatic-Hypotension Part 1 Of 6

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Click Here to Download this Blog Post –  Orthostatic Hypotension: Part 1 Of 6

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 1 of a 6 Part Series about Orthostatic-Hypotension

Orthostatic hypotension is defined as a decrease in systolic blood pressure greater than or equal to 20 mmHg or diastolic blood pressure greater than or equal to 10 mmHg within three minutes of one assuming the upright position.  Most of the time by two minutes, one could get a reliable estimate if orthostatic hypotension is present.  If someone has significant supine high blood pressure or hypotension, that is when they are lying down their blood pressure is greater than 160 systolic, we often require a systolic blood pressure drop of 30 mmHg or greater.   There are occasional rare cases where we see delayed orthostatic hypotension when the blood pressure will drop after three minutes, and this may actually represent a mild form of an abnormality of the sympathetic nervous system.  The sympathetic nervous system is like the accelerator of a car, and the parasympathetic nervous system is like the brakes of a car.  This is an analogy that we often use.   An accelerated sympathetic nervous system will raise heart rate and blood pressure

When syncope, or fainting, occurs, studies have shown that orthostatic hypotension may be responsible for about ten percent of the time for this.  In one European study, up to a quarter of syncope-associated complaints were associated with orthostatic hypotension in the emergency room.  Orthostatic hypotension, or more specifically neurogenic orthostatic hypotension, as it is often referred to, usually occurs in about one-fifth of patients over the age of 65 years of age and increases with age.  Many hospitalized patients, if they are tested, will show this, even if they are not symptomatic.  In addition, if one shows evidence of orthostatic hypotension, it is a strong predictor of future cardiovascular events and is in itself an adverse marker portending a worse prognosis in patients who have it.  Patients who have severe drops in orthostatic hypotension are even more jeopardized to have future cardiovascular events and, of course, falls as time goes on.  It is a serious disorder that needs to be recognized and treated aggressively.

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Long COVID Redefined: Major Study Uncovers Chronic Symptoms, Autonomic Dysfunction, and Overlooked Global Health Crisis – Part 5 of 5

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Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 5 of a 5 Part Series about Redefinition of Long COVID

“Long Covid” – the most important point – treatment.   Patients at times are completely disabled.  We feel that attempting to test the autonomic nervous system abnormalities and treating them pharmacologically offers the best chance of symptom improvement and functional improvement.  This is a slow fix and may take six months to one year to start seeing improvements.  We have used vasoactive agents, volume-expanding agents, and rate-lowering agents, such as beta-blockers or Corlanor,  and other agents depending on the abnormal physical findings, vital sign findings, especially with provocations, such as tilt and stand and HRV data along with sudomotor dating.  Lifestyle changes, volume expansion orally or intravenously, and antioxidant mitochondrial cocktails are also helpful in our empiric assessments.

There are several long Covid centers that sprung up.  The majority of these have closed, and when individuals look on the internet and call for appointments, they find out that a lot of them are now closed and not operating.  The ones that are operating will often see patients with Telemed and will not bring them in, nor will they test their autonomic nervous system function.  We feel that to get a proper evaluation, you need your autonomic nervous system evaluated and a treatment algorithm has to be put out aggressively as patients, many of them who are young, do indeed feel as though they are having their life taken from them by these post-viral syndromes and the sooner one could feel better symptomatically and have a better understanding of the disorder and can function better the sooner their quality of life can improve, and they can get on track.   There is no guarantee of successful treatment, but we have seen that along with other post-viral chronic fatigue states and autonomic dysfunction states, these treatment protocols are extremely effective in improving quality of life and function in many of our patients with these disorders, including the long Covid syndrome.

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Long COVID Redefined: Major Study Uncovers Chronic Symptoms, Autonomic Dysfunction, and Overlooked Global Health Crisis – Part 4 of 5

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Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 4 of a 5 Part Series about Redefinition of Long COVID

Not everyone is at risk of long Covid, although anyone can get it.  People at higher risk, according to the committee, were female sex, repeated infections, and more severe infections.

Alarmingly, it is estimated that from death certificates through 2023, The Centers for Disease Control and Prevention estimated that approximately 5000 patients in the United States have died from long Covid or from a condition in which long Covid was a contributing cause.  This number is probably much higher, in our opinion.

A very general definition of long Covid, states that it occurs three months as a continuous relapsing and remitting or progressive disease that affects one or more organ symptoms after a SARS-CoV-2 infection.  It can manifest in many ways, including singular or multiple symptoms that were described above.  To repeat, shortness of breath, cough, persistent fatigue, post-exertional malaise, difficulty concentration, memory change, recurring headache, lightheadedness, a fast heart rate, sleep disturbance, problems with taste or smell, bloating, constipation, and diarrhea.  Singular or multiple diagnosed conditions may result consisting of interstitial lung disease with low oxygen or hypoxemia, cardiac arrhythmia, such as atrial fibrillation, cognitive impairment that does not improve, mood disorders, anxiety, migraine, stroke, blood clots, chronic kidney disease, postural orthostatic tachycardia syndrome (POTS) and other forms of dysautonomia, chronic fatigue syndrome, mast cell syndromes, fibromyalgia, connective tissue disorders, hyperlipidemia, diabetes, and autonomic immune disease, such as lupus, rheumatoid arthritis, and Sjögren syndrome.

There have also been articles reporting increased incidences of ANA in people with long Covid syndrome, especially females.  We have not seen this in our testing of our patients.  We have not identified any autoimmune marker that is unique or specific for patients with long Covid syndromes.  However, we do agree with the symptom complex that the committee has set forth in the three-month cutoff that they have made.  We are not sure that long Covid is much different than any long viral or long post-bacterial infection sequelae syndrome in that they all involve autonomic nervous system dysregulation.

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Long COVID Redefined: Major Study Uncovers Chronic Symptoms, Autonomic Dysfunction, and Overlooked Global Health Crisis – Part 3 of 5

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Click Here to Download this Blog Post –  Long COVID 2025 Part 3

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 3 of a 5 Part Series about Redefinition of Long COVID

The committee stresses that asymptomatic infections or mild infections can also produce this Long Covid syndrome and is not necessarily related to the severity of the initial Covid, or even a recurrent Covid infection.  It may have a delayed onset for weeks or months and can affect children and adults.

The committee also emphasized that there are no biomarkers available to conclusively diagnose this condition.  Therefore, it is purely a clinical diagnosis, and the definition is based on clinical observations and findings.  There is no blood test available.  They emphasize that it can cause disability and affect a person’s ability to work, attend school, care for their family, and care for themselves.  This is extremely important as it causes loss of work days, work productivity, and quality of life to the individuals affected.   Many patients have described long Covid as having “taken their lives away from them”.

As we look at the features of long Covid syndromes, we note that many of them are found and even without Covid infections in individuals who have connective tissue disorders, such as Ehlers-Danlos syndrome with postural orthostatic tachycardia, mast cell abnormalities with hives, flushing, and GI-disabling symptoms, and other dysautonomia states.  Chronic fatigue, we feel, is a manifestation of an autonomic dysfunction state where one does not get adequate blood supply to the brain and gets brain fog and cognitive dysfunction associated with it.  We have previously commented on measuring the autonomic nervous system, both the sympathetic and parasympathetic branches and observing a sympathetic withdrawal state, which causes venous pooling as being a major contributor to chronic fatigue both in long Covid syndrome and in dysautonomia states in general, many of which are precipitated or triggered by viral infections.  **Therefore, although there are no biomarkers or blood tests that can diagnose long Covid syndrome, we feel that the clinical symptoms and presentation in the proper setting, along with an objective testing of the autonomic nervous system, which looks at heart rate variability often coupled with respiration rate are important to monitor.

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