Dr. Victoria Maizes

Hi, Andy.

Dr. Andrew Weil

Hi, Victoria.

Dr. Victoria Maizes

Today we will have one of our faculty at the University of Arizona, Dr. Talal Moukabary, who has become something of an expert on pots.

Dr. Andrew Weil

He is a very interesting man. I have, worked with him over the years, and I think he's very knowledgeable about not only about pots, but also symptoms of long Covid, which sometimes overlap with part.

Dr. Victoria Maizes

Let’s get him on.

Dr. Victoria Maizes

Dr. Talal Moukabary is a cardiologist at the University of Arizona Sarver Heart Center and the medical director of cardiac rehab at Banner University Medical Center in Tucson. Dr. Moukabary completed his internal medicine residency in Michigan, and he did two fellowships, one in cardiovascular medicine and one in cardiac electrophysiology. Welcome to all.

Dr. Talal Moukabary

Thank you so much for having me.

Dr. Victoria Maizes

We're delighted to have you. And we were hoping that we could speak about something that I learned about in medical school. But I have to say, it was something I almost never saw. And that's POTS it's become quite common since the Covid 19 pandemic began. So can you explain to our listeners what's POTS and, why why are we seeing so much of it?

Dr. Talal Moukabary

POTS is an abbreviation for postural orthostatic tachycardia syndrome. And let me break it down postural because it relates to the body posture meaning symptoms would change depending on the position our bodies are in. Orthostatic meaning standing up straight. So the this is in reference to the posture and meaning which posture is the one that causes the symptom.

And in this particular condition, it is standing up straight that causes it. And tachycardia is two parts “tachy” which is fast, and “cardia” refers to the heart, so the heart being fast. And it's usually called a syndrome because there is more than just that. More than that in the heart going fast when we stand up. But in short, what it what it means is when we stand up straight, in an upright position, the heart goes fast.

And it has other associated symptoms with it.

Dr. Victoria Maizes

So when I was a kid, I never told my mother this. I was afraid she'd take me to the doctor. But when I was a kid, I would get up in the morning and I'd walk along the hallway and I'd have to hold on to the banister, because sometimes I felt like, you know, I was losing my vision. Was that POTS?

Dr. Talal Moukabary

It could be. And it could not. What you were what you were really describing is a sense of, a cognitive change, an imbalance change, that was related to the change of position from being supine for most of the night to being upright. It resolved because obviously you kind of ignore that a little bit and it just went away.

Dr. Talal Moukabary

So looking back at it, for us to be able to be upright, there is a lot of things that need to work and work and the right balance for us to be able to do it. We need the muscle strength to be standing up. We need the joints and the bones to work. We need the nervous system to transmit that signal from wherever the joint is, where every bone is to our brain, and our brain needs to match it with the signals that it gets from the inner ears, and the signals that it gets from our eyes do kind of put all of them together, and then figure out where we are to send the right signals back to the muscles, to balance us. So as just from this brief description, you could guess how complicated it is. Additionally, we also need, a regulation of our blood volume, because the moment we sit, a lot of our blood volume is because of gravity shifts in down. And when we stand up, then the amount of the blood returning to the heart is less. Now, the brain would send signals to the skeletal muscles as we're walking, and it would send signals to the blood vessels to regulate that for the blood come back. But meanwhile, as we get less blood going up towards our brain, the immediate signal will go straight to the heart and tell it “Hey, I need you to go faster.”

And then the first response would be the heart going a little bit faster until there is more blood volume that comes back to it, which increases how much it could beat in every beat, how much it could get out. And then things would balance out almost. It's a it's a universal human experience. Every one of us at some point was maybe squatting, tying a shoe, and then stood up and felt lightheaded for a second.

That everybody has felt that at some point. But then in some people it's more so and it could be more in duration and it could be less in stimulus. And as for example, you might be sick, the weather might be hot, you may not have drink enough water. Or any of those variables would make you just more prone to having more of those. Now, when.

Dr. Andrew Weil

I assume that the mechanism underlying parts has to do with the autonomic nervous system, you know, some, some dysregulation of the autonomic nervous system.

Dr. Talal Moukabary

You're absolutely right. And, the autonomic nervous system autonomic because it's works on its own, which means it has its own self regulating mechanism, but it's the same as the air condition in one of our, rooms. It's supposed to regulate the temperature, and then it depends on how you set it.

So if, for example, the temperature is set at a different rate, which is not on our, control, mentally, we cannot change the autonomic nervous system. It's autonomous. Then we would deal with a lot of side effects from that.

Dr. Victoria Maizes

Andy, some of your work for I would say decades has actually been, a focus on how our autonomic nervous system broadly affects our health and maybe some of the ways that we can regulate it more than perhaps was once believed.

Dr. Andrew Weil

Yes. I've emphasized, breath control as one main method. There's, as you know, now, a lot of research on vagal stimulation and vagal toning, but you asked at the beginning, why are we seeing more of this?

Dr. Talal Moukabary

I think it's multiple causes for that. And part of it is more awareness, as, as people are aware. What Victoria mentioned, maybe if she, looked at it now, she might find something online that tells her, well, maybe you should have a doctor look at that. Versus the amount of literature and awareness that was there many years ago.

There is also, unfortunately, a lot of people are exercising less nowadays. The amount of physical activity, the amount of walking, the amount of physical activity that people do or less. We're, spending more of our time, sitting in touch and sometimes not aware of, how much hydration we had. And there is also other, conditions that relate to it is, people are less in tune with how their autonomic system, nervous system is working.

That's where some of the approaches that you have mentioned to me, I felt helpful as people get in tune and they more or less take a little bit of charge of their, regulation as they stimulate the vagus or regulate the other systems through breathing, breathing exercises and such. And the other factor that has changed recently is obviously Covid.

Covid has been the has really changed, dramatically how much we're seeing an autonomic dysfunction. It's slightly different the autonomic dysfunction that happens because of the infection is slightly different from POTS. But I see a lot of overlap. Sometimes people have one and then they get the other. Or sometimes maybe the symptoms were mild and they get exacerbated.

So there's a lot of overlap between the two conditions of what we call long Covid, which is the persistence of symptoms long after the acute infection has resolved, and POTS which is, which may have a preexisted way before Covid, or people have parts like symptoms right after the Covid infection.

Dr. Andrew Weil

How long do episodes of POTS last, typically.

Dr. Talal Moukabary

The the acute episode usually lasts until something reverses it. For example, somebody stands up, they feel the symptoms. They could sit down that get resolved immediately. But the recurrence of the symptoms, meaning how often somebody is susceptible to having them, varies a lot. In, people who get, the parts that, they typically it starts at a young age, they might be teenager.

And for many of them it, it tends to get less as they get to into their 40s. But I've seen all sorts of ages and late presentations and things that happen after an infection or other life event.

Dr. Victoria Maizes

So there's a very famous, Olympic athlete, Katie Ledecky, who has come out, with having POTS and, interestingly enough, it didn't stop her from winning Olympic medals because it's a horizontal exercise. She didn't need to work against gravity to win an Olympic medal. I just find that astonishing. But what do you think about that as a cardiologist?

Dr. Talal Moukabary

I've seen a lot of variability. This condition is really common, and what we see is probably just a small percentage of the people who have it. What I try to focus on in my clinical practice mostly is sharing what I know about it. I just feel that when people know what it is and how it works, they could just work with it or work around it and adapt their life to it.

A lot better. So we I spend a lot of my time with, with people with this condition just explaining and answering questions.

Dr. Andrew Weil

Does having parts predispose to other cardiac problems in itself?

Dr. Talal Moukabary

In it’s self it does not, but it just depends on what caused it. I think one one thing that I see clinically, is seeing people who do not have POTS, but they have pots like symptoms that I see in the clinic and other conditions like, low blood pressure, which could be a serious underlying autonomic dysfunction and other autonomic diseases could present with parts like symptoms, but they're not as benign.

And I view my task as a, as if when evaluating the patients for the first time is just to make sure there is nothing more serious than even POTS is there, and trying to understand what's the underlying mechanism for every patient POTS. Everybody is really different listening to their story and understanding what causes it. So for example, a common example, sometimes people will be on a medication that causes side effects that have similar symptoms to POTS

That's not necessarily POTS. And sometimes discussing that with them and working with the health care team, trying to figure out maybe an alternative or different dosing could elevate a lot of the symptoms.

That is, other autonomic dysfunctions that sometimes present to us as POTS, like Parkinson's or neuropathy from diabetes. They may have similar symptoms. But when one gets deeper into the story and the mechanism, you will find that we're dealing with something entirely different.

Dr. Victoria Maizes

I would love to hear, when it is POTS your initial prescription. The things I'm familiar with or things like having people change positions more slowly so that the body has a little bit more time to adjust, sometimes wearing compression stockings so that, the gravity that tends to lead us to pool blood in the legs is supported by having, external vascular support. Let's say, even not eating really big meals, because then you have the blood flowing to the digestive track and isn't available to go to the brain.

Dr. Talal Moukabary

Everything you said is absolutely right. The way I honestly look at it, in terms of patients with POTS, I tried to listen to the story, what triggers the symptoms and try to understand the mechanism for somebody, for some of them, maybe hydration is is the most important portion and for some for others, maybe it's the smaller meals.

For others, it's getting better sleep. For others, it's the compression garments. It's it's very hard to recommend them as a blanket statement to everybody. I think they need to be selected by the medical professional who's evaluating them to figure out which one of those is the right thing, and exercise I view it as an exercise prescription. It needs to it the same way you would dose a medication, you would dose exercise what's what modality and how much and how often.

So that tends to be a large part of our discussion is what kind of exercise we need to do. And there is a lot of life changes that people could make around the home. To make the home safer. For example, if somebody is having, difficulty in the shower, they may get a, a safe shower chair to prevent them from slipping in from injuries.

There's a lot of things like that. But that that changes. Good people could make around the kitchen, around the laundry room, around the the shower, and also in their bedroom in terms of temperature and, and bed height. But that really needs to be prescribed per case.

Dr. Victoria Maizes

I have been very interested in the use of vagus nerve, either stimulating devices or toning devices. These are new external tools. So there's research on the ones that get implanted in the brain. But now I'm talking about much simpler and much less expensive devices that people might put on their ear lobe or sometimes put on their chest. Sometimes, there's one approved for migraines. You put over your vagus nerve, in the neck. What's been your experience using these for POTS?

Dr. Talal Moukabary

So because the autonomic nervous system the same way if you think about the sympathetic and the parasympathetic in a way, like the brakes in the gas on a car, it's very hard to keep just one foot straight on, on the, on the brake and try to navigate the car. A lot of the external stimuli, either our body adapts or they have certain side effects or they just can't regulate things.

Right? I have not really felt that for a system that's so tuned that that might be the best approach. One approach that I have used is, what Andy taught me about breathing exercises, because I feel like it leaves it under the control of the person. They could read their body, they could tell their symptoms their system is going towards the sympathetic, so they could intentionally bring it back.

There is other advantages separate from the vagus. It's because our body is connected in a way, having changing the mental state, changing the content content of our thoughts or our emotions also play in it. It's I don't view the solution to this to be a mechanical solution.

Dr. Andrew Weil

Now, I've heard you talk about seeing many patients with long Covid with a whole variety of symptoms, including cardiac symptoms, and that you've been upset that so many of them have been told by physicians that it's all in their head, that it's not real.

Dr. Talal Moukabary

And, the, the, the there's sadly a lot of the autonomic nervous system, whether it's POTS or long Covid, the symptoms, if you open a traditional medical book, they those symptoms could map to hundreds of diseases. And they're typically they are what is described as vague nonspecific general complex. They don't point you to a specific disease directly.

That's just because the system is everywhere. And, when we try in a, in a quick medical visit to figure out if this is, a particular type of, bacteria or a particular type of infection or a particular type of tumor, then we can't pinpoint them easily. For example, a symptom like a brain fog or a chest pain or shortness of breath, they have such broad, umbrella of possibilities.

And the autonomic nervous system makes it harder for the traditional approach to pinpoint them. Sadly, many patients, they are told it's all in your head. It's all, it you're imagining it. It or it's not there. A lot of patients with POTS have, the tendency of blood pooling and their feet would literally look purple because of the blood pooling.

And when they're standing for a while, and then once they sit down or lay down, it goes away. Sometimes patients bring a picture of their feet just to show you. Look, it's real. Like I'm not imagining that my feet are turning purple and they actually do. And that's just an example of how the variability of symptoms makes it hard sometimes to detect in a clinic visits.

Also, people have good days and bad days. Sometimes people get a tilt table test that ends up being normal, and on other days they have a lot of symptoms. I think part of it is just spending the time and listening to the condition, whether it's long Covid or the pods or other autonomic nervous system disorders, to help us guide, where we go.

Dr. Victoria Maizes

Andy you teach our fellows a very simple, physical examination whether or not someone may have autonomic dysfunction? I'm wondering if you could share that with the listener.

Dr. Andrew Weil

Well, I often say that if I only have 10 minutes with a patient to make a diagnosis, I feel their hands. And if hands are cold in a warm room, that is a sure sign of overactive sympathetic activity. And that often correlates with many other things that are off balance in the body.

Dr. Victoria Maizes

And you also regularly teach people breathing exercises. Maybe you could share which are your favorite.

Dr. Andrew Weil

Well, as you know, the 4-7-8 breath I think is is a very time efficient, easy, method of increasing parasympathetic tone. And I think most people in our culture are on sympathetic overdrive for a whole variety of reasons. And it is very useful to increase parasympathetic tone. That's the relaxation response.

Dr. Victoria Maizes

What's the long term outlook? Do people get over their parts? Do they learn to manage it effectively? What do you see?

Dr. Talal Moukabary

It's both people learn to manage it, modify. Sometimes the symptoms go away as our autonomic system changes over time. As far as long Covid, I've seen it go away. But we can't say that we have had  a long track record because Covid itself is a new entity, let alone the the long consequences that happen after it. But I've seen it go away and I've seen it, I've seen it also persist. I just feel when, when people, know what the condition is and they know how to work around it, it just gives them so much power over it, that they could have better quality of life from understanding it and also from having to deal with, with the consequences of it.

Dr. Victoria Maizes

Well, that is a very hopeful message. So thank you. Thank you for that. Thank you for your work and taking care of people who are suffering with the symptoms of long Covid, sometimes not knowing for sure what causes them. And thank you for being a guest on our podcast.

Dr. Talal Moukabary

Thank you so much for having me. It's it's my honor. Thank you.