From the Guidelines
Treatment for Postural Orthostatic Tachycardia Syndrome (POTS) should prioritize a combination of lifestyle modifications, including salt and fluid loading, elevation of the head of the bed, and use of support stockings, alongside a formalized exercise program, as these interventions address the reduction in plasma volume and support long-term cardiovascular health 1.
Lifestyle Modifications
Key lifestyle modifications for POTS include:
- Salt loading through liberalized sodium intake (5-10 g or 1-2 teaspoons of table salt per day) to expand blood volume
- Drinking 3 liters of water or an electrolyte-balanced fluid per day
- Elevation of the head of the bed with 4–6-inch (10–15-cm) blocks during sleep
- Use of waist-high support stockings to ensure sufficient support of central blood volume
- Avoiding factors that contribute to dehydration, such as alcohol, caffeine, large heavy meals, and excessive heat exposure
Exercise Program
A formalized exercise program is crucial for patients with POTS, which may be best initiated in a supervised setting with a physical therapist or through specific instructions for implementation at home or in a gym 1. The program should support long-term cardiovascular health and may involve recumbent exercises initially, progressing to upright activities.
Pharmacological Interventions
While no pharmacological therapies are currently approved for POTS, various treatments may be used empirically, including:
- Low-dose beta-blockers (e.g., bisoprolol, metoprolol, nebivolol, propranolol) or nondihydropyridine calcium-channel blockers (e.g., diltiazem, verapamil) to slow the heart rate
- Ivabradine for severe fatigue exacerbated by beta-blockers and calcium-channel blockers
- Fludrocortisone (up to 0.2 mg taken at night) in conjunction with salt loading to increase blood volume
- Midodrine (2.5-10 mg) to help with orthostatic intolerance, with careful dosing to avoid excessive effects
Individualized Treatment
Treatment for POTS should be individualized, considering the variability in severity and symptom presentation among patients 1. The goal is to improve orthostatic tolerance by addressing the underlying autonomic dysfunction and cardiovascular deconditioning, thereby enhancing quality of life and reducing morbidity and mortality.
From the Research
Treatment Options for Postural Orthostatic Tachycardia Syndrome (POTS)
- Intravenous saline infusions: Studies have shown that intermittent intravenous saline infusions can dramatically reduce symptoms and improve quality of life in patients with POTS 2.
- Salt supplementation: Salt supplementation has been found to improve susceptibility to vasovagal syncope and associated symptoms in patients with POTS, with little effect on supine blood pressure 3.
- Medications:
- Propranolol, bisoprolol, and pyridostigmine have been shown to be effective in improving orthostatic intolerance symptoms, depression, and quality of life in patients with POTS 4.
- Bisoprolol and fludrocortisone have been found to improve symptoms and autonomic-hemodynamic disturbances in patients with POTS 5.
- Ivabradine, a selective inhibitor of funny sodium channels, has been shown to improve symptoms of POTS, although further research is needed to confirm its effectiveness 6.
Key Considerations
- Treatment should be individualized based on the patient's specific symptoms and needs.
- Patients with POTS may require a combination of treatments to manage their symptoms effectively.
- Further research is needed to fully understand the pathophysiology of POTS and to develop effective treatment strategies.