Working Diagnosis:
Post-COVID-19 Postural Orthostatic Tachycardia Syndrome (POTS)

Treatment:
She was initially treated with supportive measures including compression stockings, 5 grams of dietary sodium, 2 liters of fluid intake, and cardiac rehabilitation every other day. She was initially given ivabradine as it has fewer side effects than midodrine but it was not helpful for her tachycardia. She then tried midodrine to which she did not tolerate because of severe headaches. She next tried IVIG infusion with no improvement in her symptoms. Finally she had some improvement in her symptoms with the use of pyridostigmine and propranolol.

Outcome:
She has not returned to sports yet. It has been strongly recommended that she follow up with all consultants including sports cardiology, exercise physiology, pulmonary, neurology, and sports medicine.

Author's Comments:
Even athletes are susceptible to accentuated postural tachycardia and require unique treatment strategies. Shared decision making with a multidisciplinary team is crucial when determining patient management.

Editor's Comments:
Orthostatic vital signs are a useful tool in evaluating patients with dizziness and palpitations. Orthostatic hypotensoin is defined as a postural decrease in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more when measured within 3 minutes of rising from a supine to standing position. Heart rate usually will increase 15 to 30 beats with a concomitant fall in blood pressure and often correlates with a patient's complaint of dizziness. This athlete had postural tachycardia syndrome which is defined as at least 30 beats per minute increase with standing from supine position without clinically significant decrease in blood pressure. It can be confirmed with a tilt table test with either an increase of 30 beats per minute or an increase to 120 beats per minute within 10 minutes of tilt.

References:
Agarwal AK, Ritch A, Sarkar P. Postural orthostatic tachycardia syndrome. Postgrad Med J. 2007;83(981):478-480.

Cheshire WP Jr, Goldstein DA. Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res. 2019;29(2):215-230.

Johansson M, Stahlberg M, Runold M, et al. Long-Haul Post-COVID-19 Symptoms Presenting as a Variant of Postural Orthostatic Tachycardia Syndrome: The Swedish Experience [published online ahead of print, 2021 Mar 10]. JACC Case Rep. 2021.

Kanjwal K, Jamal S, Kichloo A, Grubb BP. New-onset Postural Orthostatic Tachycardia Syndrome Following Coronavirus Disease 2019 Infection. J Innov Card Rhythm Manag. 2020;11(11):4302-4304.

Miglis MG, Prieto T, Shaik R, Muppidi S, Sinn DI, Jaradeh S. A case report of postural tachycardia syndrome after COVID-19. Clin Auton Res. 2020;30(5):449-451.

Phipps D, Butler E, Stevermer JJ. PURLs: Best timing for measuring orthostatic vital signs?. J Fam Pract. 2019;68(9):512-514.

Raj SR, Arnold AC, Barboi A, et al. Long-COVID postural tachycardia syndrome: an American Autonomic Society Statement [published online ahead of print, 2021 Mar 19]. Clin Auton Res. 2021;1-4.

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