Pierson Benjamin C, Apilado Kyle, Franzos M Alaric, Allard Rhonda, Mancuso James D, Tribble David, Saunders David, Koehlmoos Tracey Perez
Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States.
Front Neurol. 2025 Jan 15;15:1515486. doi: 10.3389/fneur.2024.1515486. eCollection 2024.
Postural Orthostatic Tachycardia Syndrome (POTS) is a complex form of dysautonomia that presents with abnormal autonomic reflexes upon standing, leading to symptoms such as lightheadedness, tachycardia, fatigue, and cognitive impairment. The COVID-19 pandemic has brought renewed attention to POTS due to its overlap with post-acute sequelae of COVID-19 (PASC). Studies have found that a substantial percentage of COVID-19 survivors exhibit symptoms resembling POTS, elevating POTS diagnoses to previously unseen levels. We systematically reviewed the literature for existing high-quality evidence on potential interventions.
A systematic review of the literature was performed to identify studies of oral medications for the management of POTS. We searched for published manuscripts on the medical management of POTS through 6 April 2024 which met pre-specified inclusion criteria. We conducted quality appraisal and assessed risk of bias before extracting the data and performing synthesis to determine the current state of the evidence; particularly in the context of PASC.
The study search and selection process identified 32 studies that met inclusion criteria, comprising randomized controlled trials, observational studies, and systematic reviews. Most included studies were judged to be of moderate to high quality, with largely low risk of bias. The most frequently studied medications were beta-blockers, ivabradine, and midodrine. Ivabradine and midodrine demonstrated the highest rate of symptomatic improvement, while beta-blockers showed the largest reduction in heart rate variability. Limited evidence was available for PASC-associated POTS, but findings suggest that treatments may have similar efficacy in both PASC and non-PASC cases.
Ivabradine, midodrine, and beta-blockers currently appear to be reasonable front-line choices in pharmacologic management of POTS (PASC associated and otherwise). Further RCTs that evaluate long term outcomes of medications are needed to further establish evidence based pharmacologic treatment approaches for POTS. Particular areas of inquiry include differential efficacy of recommended therapies based on POTS subtypes, and a need for treatments directly targeting the underlying autonomic nervous system dysfunction.
PROSPERO, identifier CRD42024505967, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=505967.
体位性直立性心动过速综合征（POTS）是一种复杂的自主神经功能障碍形式，站立时会出现异常的自主神经反射，导致头晕、心动过速、疲劳和认知障碍等症状。由于与新冠病毒感染后急性后遗症（PASC）存在重叠，新冠疫情使人们对POTS重新产生关注。研究发现，相当一部分新冠病毒感染者康复后出现类似POTS的症状，导致POTS的诊断率升至前所未有的水平。我们系统地回顾了相关文献，以获取有关潜在干预措施的现有高质量证据。
对文献进行系统回顾，以确定用于治疗POTS的口服药物研究。我们检索了截至2024年4月6日发表的关于POTS药物治疗的手稿，这些手稿符合预先设定的纳入标准。在提取数据和进行综合分析以确定证据的现状之前，我们进行了质量评估并评估了偏倚风险；特别是在PASC的背景下。
研究检索和筛选过程确定了32项符合纳入标准的研究，包括随机对照试验、观察性研究和系统评价。大多数纳入研究被判定为中等至高质量，偏倚风险大多较低。研究最频繁的药物是β受体阻滞剂、伊伐布雷定和米多君。伊伐布雷定和米多君显示出最高的症状改善率；而β受体阻滞剂使心率变异性降低幅度最大。关于PASC相关POTS的证据有限，但研究结果表明，治疗方法在PASC和非PASC病例中可能具有相似的疗效。
目前，伊伐布雷定、米多君和β受体阻滞剂似乎是POTS（包括PASC相关和非PASC相关）药物治疗中合理的一线选择。需要进一步开展随机对照试验来评估药物的长期疗效，以进一步确立基于证据的POTS药物治疗方法。特别需要研究的领域包括基于POTS亚型的推荐疗法的不同疗效，以及直接针对潜在自主神经系统功能障碍的治疗需求。
PROSPERO，标识符CRD42024505967，https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=505967 。
