Case Reports of the Athletic Heart

Athletes with COVID-19: A Case Report

Question: Which of the following tests will most likely show the cause of her symptoms?

Answer: C
Tilt table testing

The patient’s symptoms are concerning for autonomic dysfunction after a viral infection. She has atypical features not concerning for angina, so a stress test or cardiac CT would not likely show ischemia. A cardiac MRI could be useful in showing inflammation but would not likely explain her symptoms. She was therefore sent for autonomic reflex testing. Valsalva maneuver also reproduced symptoms, but beat-to-beat blood pressure response was normal. Tilt table testing showed severe symptomatic orthostatic intolerance with lightheadedness, blurry vision, chest tightness, and shortness of breath with head-up tilt at 70º. End-tidal CO2 was reduced after 3 minutes in head-up tilt. She remained in regular sinus rhythm. Her heart rate increased from 61 to 116 bpm, and her blood pressure rose inappropriately, from 106/68 to 110/76 mmHg. She had reduced mean cerebral blood flow velocity in the right middle cerebral artery as much as 35% during head up tilt at 70 degrees compared with baseline, consistent with postural orthostatic tachycardia syndrome (POTS).

Authors: Christine P. Shen, MD; Sandeep R. Mehta, MD, Division of Cardiology, Scripps Clinic

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