S1066 A Hard Pill to Swallow: Dysphagia as a Primary Presenting Symptom of Postural Orthostatic Tachycardia Syndrome: An Underrecognized Association

Introduction: Postural orthostatic tachycardia syndrome (POTS) is a chronic autonomic disorder characterized by orthostatic intolerance and tachycardia. While cardiovascular and neurologic symptoms are well described, gastrointestinal (GI) manifestations are increasingly recognized. Dysphagia, though commonly associated with esophageal motility disorders, is not typically described as a presenting symptom of POTS. This study aims to characterize the prevalence and clinical features of dysphagia as an initial symptom in patients ultimately diagnosed with POTS. Methods: A retrospective chart review was conducted across 2 tertiary care centers from 2016 to 2023. Adult patients (≥18 years) with a confirmed diagnosis of POTS based on tilt-table testing were identified. Records were screened for documentation of dysphagia prior to POTS diagnosis. Swallowing studies, esophageal manometry, and autonomic testing results were reviewed. Demographic, clinical, and symptom data were analyzed. Results: Of 75 patients diagnosed with POTS, 11 (14.7%) reported dysphagia as one of their initial symptoms. Among these, 7 (63.6%) presented with oropharyngeal dysphagia, while 4 (36.4%) had esophageal symptoms. High-resolution manometry (performed in 9 patients) revealed nonspecific esophageal motility disorder in 5 (55.5%) and esophagogastric junction outflow obstruction in 2 (22.2%). All 11 patients eventually met criteria for POTS within a median of 9.3 months from symptom onset. Notably, 8 (72.7%) were initially referred to gastroenterology before autonomic dysfunction was suspected. Conclusion: Dysphagia may represent an early, underrecognized manifestation of autonomic dysfunction in POTS. Esophageal dysmotility likely contributes to symptoms, but central autonomic regulation may also play a role. Misattribution of dysphagia to primary GI etiologies may delay diagnosis. Clinicians should consider autonomic testing in patients with unexplained dysphagia and systemic symptoms such as lightheadedness, palpitations, or fatigue. Prospective studies are warranted to better define the pathophysiologic relationship and inform diagnostic algorithms.