What is the workup for Postural Orthostatic Tachycardia Syndrome (POTS)?

From the Guidelines

To manage Postural Orthostatic Tachycardia Syndrome (POTS) workup, I recommend a comprehensive evaluation starting with orthostatic vital signs, including heart rate and blood pressure measurements while lying down, sitting, and standing, as outlined in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The diagnosis of POTS typically requires a heart rate increase of at least 30 beats per minute within 10 minutes of standing, without significant blood pressure drop, as defined in the guideline 1. Initial testing should include:

• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• An ECG, as suggested in the European Heart Journal guidelines for the diagnosis and management of syncope 1 A tilt table test is often the gold standard diagnostic tool, as it can help diagnose POTS and other forms of orthostatic intolerance, such as orthostatic hypotension (OH) and orthostatic tachycardia, as described in the 2017 ACC/AHA/HRS guideline 1. Additional testing may include:
• 24-hour Holter monitoring to evaluate for arrhythmias
• Echocardiogram to assess cardiac structure and function
• Autonomic function tests to evaluate the autonomic nervous system Consider checking vitamin B12, folate, and ferritin levels to rule out deficiencies, as these can contribute to symptoms of POTS, as noted in the guideline 1. Hyperadrenergic POTS may require catecholamine testing, as outlined in the 2017 ACC/AHA/HRS guideline 1. This workup helps distinguish POTS from other causes of orthostatic intolerance, such as dehydration, anemia, or other autonomic disorders, and ensures proper diagnosis before initiating treatment, which typically includes increased fluid and salt intake, compression garments, exercise programs, and possibly medications like fludrocortisone, midodrine, or beta-blockers, depending on the clinical presentation, as recommended in the guideline 1.

From the Research

Definition and Symptoms of POTS

• Postural Orthostatic Tachycardia Syndrome (POTS) is a form of cardiovascular autonomic disorders characterized by orthostatic intolerance and a symptomatic increase in heart rate upon standing 2.
• Patients with POTS often experience symptoms such as fatigue, exercise intolerance, and gastrointestinal distress 3.
• A typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence 3.

Diagnosis and Evaluation of POTS

• The diagnostic evaluation of a patient with suspected POTS requires a thoughtful diagnostic approach utilizing a careful clinical history and examination, laboratory, and autonomic testing 4.
• The evaluation of a patient with suspected POTS should seek to establish the diagnosis, identify co-morbid conditions, and exclude conditions that could cause or mimic the syndrome 3.
• Autonomic testing is used to confirm a POTS diagnosis, exclude other causes of orthostatic intolerance, and may provide for characterization of POTS into neuropathic and hyperadrenergic subtypes 4.

Management and Treatment of POTS

• Management of POTS typically begins with patient education and non-pharmacologic treatment options, such as increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2.
• Various medications are often used to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS, and evidence for many of the medications used to treat POTS is not robust 2, 3.
• Recent studies have identified three primary POTS phenotypes - hyperadrenergic, neuropathic, and hypovolemic - each requiring tailored management strategies 2.