Postural Orthostatic Tachycardia Syndrome (POTS): Recognition, Management, and Living Well (Autonomic Disorders)

Postural orthostatic tachycardia syndrome (POTS) is a condition characterized by significant increases in heart rate when standing up from a lying position. It is a complex autonomic disorder affecting blood flow, heart function, and the nervous system.1 Predominantly impacting premenopausal women, though not exclusively, the syndrome can manifest a range of symptoms.1

In this article, Crystal Run Healthcare explains what causes POTS, how to diagnose POTS, and how to manage POTS. Understanding this condition is the first step toward managing its symptoms and improving the quality of life for those affected.

Understanding POTS

Postural orthostatic tachycardia syndrome is a form of dysautonomia that is characterized by an excessive heart rate increase when moving from a reclining to an upright position.1 The heart rate can jump by more than 30 beats per minute or exceed 120 beats per minute within the first 10 minutes of standing, a response not due to orthostatic hypotension (a significant drop in blood pressure upon standing).1,2

POTS is part of a broader category of disorders known as orthostatic intolerance, which results in a decrease in blood flow to the heart when a person stands up from a lying-down position.2

The exact causes of POTS remain unclear.2 Researchers have identified multiple subtypes of POTS, including:

• Neuropathic POTS - Thought to be caused by a dysfunction in the nerves that typically help to constrict blood vessels to counteract gravity's effect on blood when we stand. This type leads to blood pooling in the veins of the legs and a diminished response to blood flow back to the heart and brain.1
• Hyperadrenergic POTS - Characterized by an excessive release of norepinephrine, a neurotransmitter that is part of the body’s fight-or-flight response, which causes an abnormal increase in heart rate, blood pressure, and symptoms of increased sympathetic nervous system activity such as tremors and palpitations.1
• Hypovolemic POTS - Where there is an abnormally low amount of blood plasma, leading to difficulties in maintaining adequate blood flow and pressure throughout the body.1
• Autoimmune POTS - Some patients exhibit signs of an underlying autoimmune condition where the immune system mistakenly attacks the body’s own tissues, potentially triggering the symptoms of POTS.1

POTS mainly affects women between the ages of 15 and 50.1 The reasons for this are not fully understood, but many patients report an onset of symptoms following major life events that stress the body, such as pregnancy, major surgery, trauma, or viral illnesses.2 POTS sufferers also have an increased risk of developing low cerebrospinal fluid pressure (low CSF pressure) headaches, which are triggered by a decrease in the volume or pressure of the fluid surrounding the brain and spinal cord.3

Symptoms and Diagnosis

The primary symptom of POTS is a significant heart rate increase upon standing, as mentioned previously. However, people with POTS often experience a range of other symptoms that can affect various systems of the body. Common POTS symptoms include chronic fatigue, lightheadedness, palpitations, nausea, dizziness, headaches, and sleep disturbances.1

Diagnosing POTS requires careful evaluation because its symptoms overlap with those of many other conditions, including various autoimmune disorders.1 The process begins with a thorough patient history and a physical examination aimed at ruling out other potential causes. Diagnosing POTS often includes an active stand test or a head-up tilt table test.1

During these tests, the patient's heart rate and blood pressure are measured in a controlled environment when changing from a prone to an upright position. A diagnosis of POTS is confirmed if there is an increase in heart rate of at least 30 beats per minute within 10 minutes of standing or tilting, without significant drops in blood pressure.1

Management Strategies

Managing postural orthostatic tachycardia syndrome involves a combination of non-pharmacological and pharmacological strategies, customized to the individual's symptoms and subtype of POTS.

• Non-pharmacological interventions are generally the first line of treatment and include:
• Increased fluid intake - Recommending 2-3 liters of fluids per day to improve blood volume.
• Dietary changes - Adding extra salt in the diet (up to 10 grams per day) to help increase blood volume and pressure.
• Physical counter-maneuvers - Techniques such as leg crossing can help mitigate symptoms by promoting venous return.
• Compression garments - Wearing compression stockings can help prevent blood pooling in the legs.
• Exercise - A structured and gradual exercise program, starting with recumbent or horizontal exercises like swimming or rowing, can help improve cardiovascular fitness without exacerbating symptoms.1

Pharmacological treatment may be considered in more severe or refractory cases:

• Fludrocortisone - Used to increase blood volume and sodium retention.
• Beta-blockers - Such as propranolol, can be used to control heart rate.
• Midodrine - An alpha-1 adrenergic agonist that increases vascular tone and helps elevate blood pressure.1

Support and Treatment at Crystal Run Healthcare

At Crystal Run Healthcare, we understand the challenges faced by individuals diagnosed with postural orthostatic tachycardia syndrome, and we are dedicated to providing comprehensive support and effective treatment for each patient. Ourteam of specialists is highly experienced in the complexities of POTS and committed to employing a holistic approach to care.

If you are experiencing symptoms of POTS and seeking support, Crystal Run Healthcare is here to help. We offer a range of diagnostic services to accurately identify POTS and a multidisciplinary treatment approach that includes both lifestyle modifications and medication management. At Crystal Run, our goal is to not only relieve the symptoms associated with POTS but also to improve your overall quality of life.

Sources

1. National Center for Biotechnology Information. Postural Orthostatic Tachycardia Syndrome, Updated 8/7/2023.Postural Orthostatic Tachycardia Syndrome | National Center for Biotechnology Information. Accessed 5/1/2024
2. National Institute of Neurological Disorders and Stroke (NIH). Postural Tachycardia Syndrome (POTS), Updated 11/28/2023.Postural Tachycardia Syndrome (POTS) | NIH. Accessed 5/1/2024
3. American Migraine Foundation. Low CSF Pressure Headache: An Introduction, Updated 11/21/2019.Low CSF Pressure Headache: An Introduction | American Migraine Foundation. Accessed 5/1/2024