STARS Healthcare Pioneers Report

Showcasing Best Practice In Syncope

Can an earlier diagnosis of PoTS improve outcomes?

Dr Shamil Yusuf, Ms Helen Eftekhari, Ms Geeta Paul, Ms Sarah Abbott, Ms Albiona Zhupaj
University Hospitals Coventry & Warwickshire, Coventry, UK; University of Warwick (HE)

Introduction

In UK, on average, it takes seven years to achieve a diagnosis of postural tachycardia syndrome (PoTS), which can have a significant impact on quality of life, including having to stop studying and working. The 2018 European Society of Cardiology (ESC) syncope guidelines identify more evidence of the role of nurses in syncope clinics. Arrhythmia nurses and one lead syncope electrophysiology consultant run our syncope clinic. The nurses are trained in health assessment and prescribing, seeing 75% of patients.

Patient history and tests

A previously fit, active 19-year-old (Ms C) was referred to the multidisciplinary Syncope & PoTS clinic following a recent A&E attendance, reviewed by our nurse. She has attended A&E eight times in the past two months with a six-month history of palpitation and near syncope. The symptoms were scaring her.

Throughout the COVID-19 lockdown, she was studying in bed and staying in her room all day. After three months, her symptoms began and she stopped her studies. Fluid intake <1.4L (including two cans of cola) and her diet was high in refined carbohydrates.

Electrocardiogram (ECG) and symptom correlation on Holter monitoring showed sinus tachycardia. Normal findings: echo, exam, routine bloods including thyroid, and 9am cortisol metanephrines. Of note, tilt table testing has a three-month wait. Ten-minute clinic active stand found delta heart rate 48bpm corresponding to symptoms. Average blood pressure was 105/68. Also, she had a Beighton score of 4 for joint hypermobility.

Diagnosis & management

Deconditioning PoTS • Education & counselling on PoTS, symptoms & prognosis.

• Fluids front loading, aiming for 2.5 litre and good quality fluids.

• Salt intake to aim for 10g per day.

• Dietary changes: small frequent meals, with minimal refined carbohydrates.

• Home exercise programme given to start with recumbent exercises.

• Aim to return to studies.

At a virtual review at five months, there had been no further A&E attendances & she returned to college. Delta heart rate 21bpm undertaken at home with patient’s iWatch. Significant improvement in symptoms & patient reassured by active stand results.

Conclusion

Earlier diagnosis of PoTS can improve outcomes.

• 10-minute active stand test can help facilitate diagnosis & management.

• PoTS management can reduce healthcare costs, in this case A&E attendances.

• Nurses trained with health assessment skills and syncope & PoTS can be integral to running a syncope & PoTS service. 

 

Can an earlier diagnosis of PoTS improve outcomes?

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