Facts about Postural Orthostatic Tachycardia Syndrome

POTS—Overview.

Postural Orthostatic Tachycardia Syndrome is a chronic autonomic nervous system condition that causes an abnormal increase in heart rate (≥30 bpm in adults, ≥40 bpm in adolescents) within 10 minutes of standing, without a significant reduction in blood pressure. It is becoming more common worldwide. Orthostatic intolerance is distinguished by increased heart rate, dizziness, fatigue, and palpitations when standing. The condition is characterized by a dysfunction in the autonomic control of blood flow and heart rate.

Criteria for diagnosis:

• Within 10 minutes of standing or tilt-table testing, the heart rate increases by at least 30 bpm in adults and 40 bpm in adolescents.
• There is no orthostatic hypotension (a decrease in systolic or diastolic blood pressure of ≥20 mmHg).
• Measure heart rate and blood pressure with a tilt-table or active stand test.
• Rule out other causes: Dehydration, blood loss, or orthostatic hypotension

Who is affected?

• Demographics: Predominantly affects women aged 15-50.
• Associated Conditions: Possible after viral infection, trauma, surgery, or pregnancy. This condition is often associated with autoimmune diseases, Ehlers-Danlos syndrome, and CFS.

Management and Treatment

• Lifestyle changes: 
• Increased hydration and salt intake.
• Utilize compression stockings for better circulation.
• Implement gradual exercise programs such as recumbent cycling and swimming.
• Beta-blockers (heart rate reduction).
• Fludrocortisone is used to increase blood volume.
• Midodrine improves vascular tone.
• With no cure, care focuses on symptom control and everyday function.

Risks and Factors Misdiagnosis risk: POTS is commonly misdiagnosed as anxiety, persistent fatigue, or dehydration. 

• Long-term impact: Can drastically reduce quality of life, although not life-threatening.
• Research gaps: The cause of POTS is uncertain, and ongoing investigations are exploring autoimmune and genetic factors.

Can POTS be cured?

• There is no cure for POTS. Many people see significant improvement with lifestyle modifications, medications, and physical training, and some symptoms may disappear.

Can POTS Go Away?

• No standard treatment eliminates POTS permanently.
• Proper care can reduce symptoms and perhaps induce remission. Some individuals with POTS experience symptoms for a lifetime, while others may improve after months or years, particularly if their symptoms developed following a viral illness or surgery.

Medications:

• Beta-blockers (lower heart rate).
• Increase blood volume using fludrocortisone.
• Midodrine promotes vascular tone.
• Ivabradine (Corlanor) could reduce tachycardia without lowering blood pressure off-label.

POTS symptoms

Standing upright causes POTS symptoms, including rapid heartbeat, dizziness, fainting, weariness, and “brain fog.” These symptoms range in severity and may have an impact on daily life.

Key Symptoms of POTS: 

• Cardiovascular:
• Rapid heartbeat within 10 minutes of standing 
• Palpitations or pounding heart, Chest discomfort, Neurological:
• Dizziness or lightheadedness, Syncope or near-fainting episodes, Concentration issues (brain fog)
• Headaches

General/Systemic:

• Excessive weariness and exercise intolerance 
• Leg weakness • Nausea, bloating, or abdominal pain • Sweating irregularities
• Other features:
• Symptoms intensify in hot weather due to heat intolerance.
• Acrocyanosis (bluish staining of feet/hands when standing) • Sleep disruptions

Symptom Causes

• Prolonged standing (queues, showers, cooking) • Heat exposure (summer weather, hot baths) • Dehydration • Stress or illness • Sudden postural changes

Causes

Autonomic nerve system failure causes Postural Orthostatic Tachycardia Syndrome (POTS), which affects heart rate and blood flow when standing. It commonly follows viral infections, autoimmune diseases, trauma, or genetic connective tissue problems.

The main causes and contributing factors are:

1. ANS dysfunction

• The autonomic nervous system fails to regulate blood vessel constriction and heart rate adequately.
• Excessive tachycardia occurs when standing, without the typical blood pressure decline of orthostatic hypotension.

2. Abnormal blood volume

• Patients with hypovolemia may have lower circulating blood volume.
• The legs and abdomen may experience blood pooling, resulting in decreased blood return to the heart and compensatory tachycardia.

3. Autoimmune Links

• POTS is linked to autoimmune illnesses such as lupus, Sjögren's syndrome, and Hashimoto's thyroiditis.
• Autoantibodies can disrupt autonomic nerve signals.

4. Genetic/Connective Tissue Disorders

• Ehlers-Danlos syndrome (EDS): Weak connective tissue causes excessive blood pooling.
• Familial predisposition: Possible hereditary influence.

5. Post-Viral or Post-Traumatic Onset 

• Patients often experience POTS symptoms after: 
• Viruses like Epstein-Barr and COVID-19 often cause POTS symptoms.
• Surgery, trauma, or pregnancy.

6. Other Contributors

• Prolonged bed rest or inactivity might increase signs of deconditioning.
• Hormonal factors: Most prevalent in women, suggesting estrogen/progesterone involvement.
• Neuropathy may cause POTS by damaging tiny nerve fibers that govern blood vessel constriction.

Key Notes

• POTS is multifaceted, with no single etiology explaining all cases.
• The cause is generally a combination of autonomic dysfunction, blood pooling, autoimmune activity, and hereditary predisposition.
• Knowing the cause helps create personalised treatments, like increasing blood volume for low blood levels, using compression garments for blood pooling, and adjusting the immune system for autoimmune-related POTS

Treating POTS

The video about how PTOS is treated

Lifestyle adjustments, physical training, and drugs to minimize symptoms, including rapid heartbeat, dizziness, and exhaustion, are used to treat Postural Orthostatic Tachycardia Syndrome (POTS). A structured management plan is beneficial for most patients.

Also, read https://www.dysautonomiainternational.org/page.php?ID=30

Main Treatment Methods

1. Lifestyle changes

• Hydrate and salt: Increase fluid intake (2-3 litres/day) and dietary sodium (3-10 g/day, under medical advice) to increase blood volume.
• Compression Garments: Waist-high stockings or abdominal binders minimize leg blood pooling.
• Exercise Therapy: Start with recumbent or semi-reclined exercises (e.g., rowing, swimming, cycling) and graduate to upright activities.
• Posture Strategies: Reduce prolonged standing, rise slowly, and utilize physical counter-maneuvers (leg crossing, muscle tensing).

2. Symptom-based Heart Rate Control: • Beta-blockers (e.g., propranolol, metoprolol) are recommended.

• Ivabradine (off-label, decreases heart rate without reducing blood pressure)
• Support for blood pressure and circulation:
• Fludrocortisone (blood volume increase)
• Midodrine (increases blood vessel tightness and standing tolerance)
• Autonomic Modulation:
• SSRIs and SNRIs are used to treat anxiety and autonomic dysfunction.
• Pyridostigmine (boosts parasympathetic activity)

3. Physiotherapist-supervised graded exercise regimens enhance cardiovascular fitness. 

• Begin with horizontal workouts and gradually graduate to upright training.

4. Helpful Things

• Adjusted diet: Smaller, frequent meals to prevent postprandial symptoms.
• Ensure temperature management by avoiding hot situations and showers.
• Sleep hygiene: Restful sleep enhances autonomic stability.

Risks and Factors

• Each patient responds differently to therapies, requiring individualized programs.
• Side effects of medications: Beta-blockers may induce weariness, fludrocortisone may increase blood pressure, and midodrine may cause goosebumps or urinary retention.
• POTS misdiagnosis: Commonly misdiagnosed as worry or persistent exhaustion, delaying treatment.
• Long-term prognosis: Although treatment often results in improvement, relapses are possible.

Life expectancy with POTS

Chronic, non-fatal Postural Orthostatic Tachycardia Syndrome (POTS) rarely shortens life. Most patients have a favorable long-term outlook, even if it can produce severe symptoms like COPD or congestive heart failure.

Conclusion

Postural Orthostatic Tachycardia Syndrome, a complicated, multivariate autonomic nervous system illness, mostly affects young women but can impact anyone. It causes dizziness, weariness, palpitations, and cognitive issues due to an irregular heart rate spike when standing.  POTS is controllable, not curable, and many individuals regain independence and stability with proper treatment.