Athletes with COVID-19: A Case Report

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

Discussion We report a case of POTS developing after COVID-19 infection in a competitive athlete. Based on the definition of POTS put forth by the 2015 Heart Rhythm Society Expert Consensus Statement, the patient qualifies for POTS based on symptoms, an increase in heart rate of at least 30 bpm when moving from recumbent to standing position, and the absence of orthostatic hypotension (1). A holter or patch monitor can assess for heart rate variability and exclude reentrant tachycardias. The autonomic reflex test is used to diagnose POTS is the passive head-up tilt table testing. Blood pressure and heart rate are measured continuously or at fixed intervals while supine and following an incline to greater than 60 degrees, and cerebral blood flow can show reductions in middle cerebral artery blood flow velocity measured by transcranial Doppler (2). Patients often do not have pre-existing symptoms of autonomic impairment. Infection is a well-described trigger for POTS. It has been hypothesized that decreased parasympathetic activity and increased sympathetic activity may be associated with poor outcomes for COVID-19 (3). There has been a report of a young field hockey player with infectious mononucleosis-induced POTS whose symptoms resolved after six weeks {4). In addition, there is a previously reported case of POTS after COVID-19, with symptoms persisting for 5.5 months at the time of publication (5). It is unclear what long-term effect COVID-19-induced POTS may have on competitive athletes. There is growing evidence that the abrupt onset of POTS may have an autoimmune etiology (6). Whether the immune response to COVID-19 led to POTS in this case is an intriguing hypothesis requiring future study. Most of the treatment for POTS focuses on patient education and managing expectations. The treatment is collaborative and multi-disciplinary. Medications that can worsen POTS (such as angiotensin-converting enzyme inhibitors, alpha receptor blockers, tricyclic antidepressants, opiates, and diuretics) should be discontinued. Patients should start a graded, structured, and supervised exercise program, starting with non-upright exercises. Patients should drink 2-3 L of water per day, consume salt 10-12 g/day, and wear compression stockings. Blood volume is reduced in up to 70% of patients with POTS1. Fludrocortisone and Midodrine have been used if necessary. Propranolol at a low-dose can reduce unpleasant sinus tachycardia and palpitations. The effect of COVID-19 on athletes is currently under study. It has been shown that there can be myocardial inflammation after recovery from COVID-19 in competitive athletes, and this is associated with poor outcomes, including myocardial dysfunction and mortality (7) (8). The management of an athlete with COVID-19 depends on the severity of symptoms, and it is recommended that training resume when symptoms completely resolve and energy levels return to normal, starting with low-intensity indoor training during in-home isolation (9). In addition, training modification has been suggested with limiting the time and intensity of sessions to mitigate the immune system depression that can occur with prolonged and strenuous training. Our patient is implementing lifestyle changes currently. Take home message Postural orthostatic tachycardia syndrome can develop after COVID-19 infection, causing prolonged exertional intolerance that can be particularly disabling to a competitive athlete. This can be diagnosed with a tilt table test, and it is best treated initially with lifestyle management with salt and fluid loading, compression stockings, and graded exercise.

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