From the Guidelines
Postural increased heart rate, also known as postural tachycardia, is best managed by addressing the underlying condition, such as postural orthostatic tachycardia syndrome (POTS), with a comprehensive approach including lifestyle modifications, physical countermeasures, and medications as needed, prioritizing patient education and individualized care to improve morbidity, mortality, and quality of life. According to the 2018 ESC guidelines for the diagnosis and management of syncope 1, POTS is characterized by an inappropriate heart rate increase without concomitant blood pressure fall, likely due to severe deconditioning, immune-mediated processes, excessive venous pooling, and hyperadrenergic state. Key features of POTS include:
- Orthostatic intolerance with symptoms such as light-headedness, palpitations, tremor, weakness, blurred vision, and fatigue
- Heart rate increase of at least 30 beats per minute within 10 minutes of standing
- Absence of other causes of tachycardia Management strategies for POTS may involve:
- Increased fluid intake (2-3 liters daily) and salt consumption (8-10 grams daily) to expand blood volume
- Physical countermeasures like compression garments for the lower body to prevent blood pooling
- Regular, gradual exercise focusing on recumbent activities initially to improve cardiovascular function
- Medications such as beta-blockers (e.g., propranolol 10-40 mg) to control heart rate, fludrocortisone (0.1-0.2 mg daily) to increase blood volume, or midodrine (2.5-10 mg three times daily) to constrict blood vessels, as needed and under medical supervision. It is essential to note that the severity of symptoms varies widely among patients, and individualized care is crucial to address the specific needs and improve outcomes 1.
From the Research
Postural Increased Heart Rate
- Postural Orthostatic Tachycardia Syndrome (POTS) is a condition characterized by an excessive increase in heart rate upon standing, often accompanied by symptoms such as lightheadedness, fatigue, and brain fog 2, 3, 4.
- The pathophysiology of POTS is complex and multifactorial, involving various mechanisms such as hyperadrenergic, neuropathic, and hypovolemic responses 2.
- Diagnosis of POTS typically involves evaluating the patient's heart rate response to standing or tilt testing, with a criterion of ≥30 bpm increase in heart rate 5.
- However, the optimal cut point values for diagnosing POTS may vary depending on the testing method used, with tilt testing producing larger heart rate increases than active standing 5.
- Orthostatic heart rate changes have also been studied in patients with heart failure, where poor orthostatic heart rate changes were associated with a worse prognosis 6.
- Management of POTS typically involves lifestyle modifications, such as increased fluid and salt intake, compression garment use, physical reconditioning, and postural training, as well as pharmacologic therapies to manage specific symptoms 2, 3.