What are the symptoms and treatment options for Postural Orthostatic Tachycardia Syndrome (POTS)?

Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)

Postural Orthostatic Tachycardia Syndrome (POTS) is characterized by severe orthostatic intolerance with a marked heart rate increase upon standing, accompanied by symptoms including lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, and fatigue, without significant blood pressure drop.

Diagnostic Criteria

POTS is defined by the following criteria:

• An increase in heart rate of ≥30 beats per minute (≥40 bpm in adolescents 12-19 years) within 10 minutes of standing or head-up tilt 1
• Heart rate often exceeds 120 beats per minute when standing 1
• Absence of orthostatic hypotension (no sustained drop in systolic blood pressure ≥20 mmHg) 1
• Symptoms of orthostatic intolerance that improve when returning to supine position 1
• Symptoms persisting for at least 3 months 1

Primary Symptoms

The most common symptoms of POTS include:

1. Orthostatic symptoms (occur upon standing):

   • Lightheadedness/dizziness
   • Palpitations
   • Tremulousness
   • Generalized weakness
   • Blurred vision
   • Exercise intolerance
   • Fatigue 1

2. Autonomic activation symptoms:

   • Pallor
   • Sweating
   • Nausea 1

3. Sensory disturbances:

   • Visual disturbances (blurring, enhanced brightness, loss of color, tunnel vision)
   • Hearing disturbances (impaired hearing, crackles, tinnitus) 1

Associated Symptoms and Comorbidities

POTS is frequently associated with:

• Chronic fatigue syndrome
• Joint hypermobility syndrome
• Headaches and migraines
• Gastrointestinal symptoms (bloating, nausea, diarrhea, abdominal pain)
• Sleep disturbances
• Cognitive difficulties ("brain fog")
• Fibromyalgia
• Visceral pain and dysmotility
• Mitral valve prolapse 1, 2, 3

Symptom Patterns and Triggers

Symptoms typically:

• Develop upon standing
• Are relieved by sitting or lying down
• May worsen in the morning
• Exacerbate with heat exposure
• Worsen after meals or physical exertion 1

POTS may be precipitated by:

• Deconditioning
• Recent infections
• Trauma
• Prolonged bed rest 1, 3

Pathophysiologic Mechanisms

The pathophysiology of POTS is heterogeneous and may include:

• Deconditioning
• Immune-mediated processes
• Excessive venous pooling
• Hyperadrenergic state
• Limited autonomic neuropathy
• Hypovolemia 1, 2, 4, 5

Clinical Considerations

• POTS is approximately five times more common in women than men 2
• Typical onset is in adolescence or young adulthood 6
• Symptoms often begin after a period of inactivity from illness or injury 6
• POTS is distinct from classical orthostatic hypotension, as blood pressure is maintained despite tachycardia 1
• COVID-19 has been identified as a potential trigger for POTS, with similar symptoms occurring as part of post-acute sequelae of SARS-CoV-2 infection 1

Common Pitfalls in Diagnosis

• Failing to distinguish POTS from anxiety disorders or panic attacks
• Overlooking POTS in patients with multiple somatic complaints
• Not performing proper orthostatic vital sign measurements (heart rate should be measured after standing for 10 minutes)
• Confusing POTS with inappropriate sinus tachycardia or other cardiac arrhythmias
• Missing the diagnosis in adolescents where the heart rate increase criterion is higher (≥40 bpm)

Understanding the constellation of symptoms and diagnostic criteria for POTS is essential for proper identification and management of this challenging condition that significantly impacts quality of life.