A Guide to POTS Syndrome Written By Cardiologists
The following is a typical presentation of a POTS patient. A 32-year-old woman went to the Dr with complaints of fatigue, episodes of mental fogginess, bad migraines, and frequent light headed episodes. She has almost passed out on several occasions, usually when in a standing position. She was in normal health until 4 months ago when she was ill and told she had a virus. She feels she never recovered after that. Her heart frequently races and of course she is very scared of her symptoms.
To investigate these symptoms the Dr performed a number of tests that included a heart tracing and scan, blood tests and an MRI scan of her brain. None of the tests showed any abnormalities. She is very frustrated as her quality of life has been severely affected and no one can give her any good answers other than that she must have an anxiety disorder.
She then goes to see another Dr after a friend of hers with similar symptoms that she met online advised her to. It is noticed that when she stands she has an increase in heart rate and feelings of light-headedness.
Definition of POTS – Postural Orthostatic Tachycardia Syndrome
POTS syndrome is defined as symptoms such as those mentioned above, combined with a heart rate that increases by 30 beats per minute (or heart rate >120 beats per minute) within 10 minutes of standing up. Other conditions that can cause similar symptoms should be ruled out. There is a wide spectrum of POTS syndrome like disorders that falls under the umbrella of dysautonomia, several of which do not have the increase in heart rate.
POTS is a dysautonomia
The autonomic nervous system is basically the system that regulates involuntary actions that allow the body to function normally. When we stand for example, the body needs to accommodate an entire set of processes to allow this. On standing a significant amount of blood automatically falls to the lower body. Autonomic reflexes ensure that blood gets appropriately distributed to the upper body by changes such as muscle tone, vessel tone and heart rate and pumping responses.
There is a range of diseases that affect the autonomic nervous system known as dysautonomia and POTS is one of them. In POTS there is increase in heart rate and light-headedness on standing. In addition there is exercise intolerance and fatigue, often with a multitude of other symptoms. POTS may be so severe that even normal everyday activities usually taken for granted such as bathing or walking may be severely limited.
What happened to our typical POTS patient?
Our patient was relieved that she had been referred to a Dr that recognized her symptoms instead of simply dismissing them due to normal routine tests. It was noticed that she had a 35-point increase in heart rate after 5 minutes of standing. She was diagnosed with POTS.
She formulated a treatment plan with her physician and initially tried a number of measures. She commenced an exercise plan, and although this was very hard at first, she started slowly and built up to where she was doing up to an hour, 4 times a week. This included core exercises to build up her leg and stomach muscles. She increased her fluid intake and salt intake.
Initially she took a beta-blocker and anti-migraine medicines. She was able to wean off the migraine medication within a year. After a year she felt much better able to manage her symptoms that were now much less frequent. She did not feel as limited and had significant improvement in her quality of life.
References & Resources
Adolescent fatigue, POTS, and recovery: a guide for clinicians. Kizilbash et al. A comprehensive review of POTS, mainly written for clinicians, excellently written.
Postural tachycardia syndrome (POTS). Raj. An excellent review article on POTS in a highly reputable journal.
Postural tachycardia syndrome: a heterogeneous and multifactorial disorder. Benarroch et al. A review article on POTS.
Original Research Articles
Risk factors for postural tachycardia syndrome in children and adolescents. Lin et al. Article from China. Faster laying down HR, less water intake and shorter sleeping hours were identified as risk factors for POTS.
Sleep disturbances and autonomic dysfunction in patients with postural orthostatic tachycardia syndrome. Mallien et al. Article examining sleep patterns and disorders in POTS patients. POTS patients had a subjective diminished sleep quality, reached higher levels of daytime sleepiness, and showed a higher proportion of stage 2 sleep.
Acute volume loading and exercise capacity in postural tachycardia syndrome. Figueroa et al. Findings suggest that acute volume loading with IV saline does not improve VO2peak or cardiovascular responses to exercise in POTS, but does improve resting hemodynamic function.
Cognitive function, health-related quality of life, and symptoms of depression and anxiety sensitivity are impaired in patients with the postural orthostatic tachycardia syndrome (POTS). Anderson et al. The description is in the title!
Postural tachycardia syndrome is associated with significant symptoms and functional impairment predominantly affecting young women: a UK perspective. Mcdonald et al. A UK perspective on POTS.
Autoimmune basis for postural tachycardia syndrome. Lee et al. Article looking at the potential role of autoantibodies in POTS.
Gastric emptying in postural tachycardia syndrome: a preliminary report. Park et al. Article demonstrating that over one-third of patients with POTS and gastrointestinal symptoms have abnormal, more frequently rapid than delayed gastric emptying.
Low-dose propranolol and exercise capacity in postural tachycardia syndrome: a randomized study. Arnold et al. This study provides Class II evidence that a single low dose of propranolol (20 mg) as compared with placebo is useful in increasing maximum exercise capacity measured 1 hour after medication.
Orthostatic symptoms does not always manifest during tilt-table test in pediatric postural orthostatic tachycardia syndrome patients. Huh et al. Significant patients with POTS did not present orthostatic symptoms during the tilt table test despite having chronic daily symptoms.
Nitric oxide and regulation of heart rate in patients with postural tachycardia syndrome and healthy subjects. Gamboa et al. An article exploring the role of nitric oxide in the pathophysiology of POTS.
Clinical characteristics of a novel subgroup of chronic fatigue syndrome patients with postural orthostatic tachycardia syndrome. Lewis et al. A paper examining the link between chronic fatigue syndrome and POTS.
Deconditioning in patients with orthostatic intolerance. Parsaik at al. An article demonstrating the importance of conditioning in POTS.
A prospective, 1-year follow-up study of postural tachycardia syndrome. Kimpinski et al. Orthostatic symptoms improved in patients, with more than one-third of patients no longer fulfilling tilt criteria for POTS, although the overall group change in heart rate increment was modest.
Anxiety in patients with postural tachycardia syndrome (POTS). Wagner et al. POTS patients do not exhibit signals of anxiety disorders more often than control groups, provided that questionnaires without autonomic items are used.
Short-term exercise training improves the cardiovascular response to exercise in the postural orthostatic tachycardia syndrome. Shibata et al. Short-term exercise training improves physical fitness and cardiovascular responses during exercise in patients with POTS.
Desmopressin acutely decreases tachycardia and improves symptoms in the postural tachycardia syndrome. Coffin et al. Article demonstrating potentially helpful role of desmopressin in POTS.
Clinical presentation and management of patients with hyperadrenergic postural orthostatic tachycardia syndrome. A single center experience. Kanjwal et al. Article looking at features of hyperadrenergic POTS.
Exercise training versus propranolol in the treatment of the postural orthostatic tachycardia syndrome. Fu et al. Article emphasizing the important of exercise in POTS.
Sleep disturbances and diminished quality of life in postural tachycardia syndrome. Bagai et al. Article looking at the relationship between POTS and sleep disturbances.
Single centre experience of ivabradine in postural orthostatic tachycardia syndrome. Mcdonald et al. An article evaluating the potential role of the heart slowing drug Ivabradine in POTS.
Cardiac origins of the postural orthostatic tachycardia syndrome. Fu et al. An article demonstrating the smaller heart of POTS syndrome and the importance of exercise training.
Postural orthostatic tachycardia syndrome: the Mayo clinic experience. Thieben et al. An article looking at characteristics of a relatively large series of POTS patients.
Acetylcholinesterase inhibition improves tachycardia in postural tachycardia syndrome. Raj et al. An article evaluating the effects of Pyridostigmine in POTS.
Other Names for POTS
- Postural Tachycardia Syndrome
- Postural Tachycardia
- Postural Tachycardia Disease
- POTS Syndrome
- POTS Disease
- P.O.T.S. Syndrome
- P.O.T.S. Disease