From the Guidelines
POTS (Postural Orthostatic Tachycardia Syndrome) is a condition characterized by a rapid heart rate increase of at least 30 beats per minute within 10 minutes of standing, often accompanied by dizziness, lightheadedness, fatigue, and sometimes fainting, as defined in the 2018 ESC guidelines for the diagnosis and management of syncope 1.
Key Symptoms and Diagnosis
The primary symptoms of POTS include:
- Dizziness, light-headedness, weakness, fatigue, and lethargy
- Palpitations, which may refer to abnormal beats or sinus tachycardia
- Pallor, sweating, and/or nausea, indicating autonomic activation
- Pain in the neck and shoulder region, low back pain, or precordial pain
- Hearing disturbances, such as impaired hearing or tinnitus
- Visual disturbances, including blurring, enhanced brightness, or loss of color These symptoms typically develop upon standing, are relieved by sitting or lying, and may be worse in the morning, with heat exposure, and after meals or exertion 1.
Pathophysiology and Treatment
The pathophysiology of POTS is debated and likely heterogeneous, with proposed mechanisms including deconditioning, immune-mediated processes, excessive venous pooling, and a hyperadrenergic state 1. Treatment typically includes:
- Increased fluid intake (2-3 liters daily) and salt consumption (3-10g daily)
- Regular exercise focusing on reclined activities initially
- Compression garments for the lower body
- Medications like beta-blockers (propranolol), fludrocortisone, or midodrine in more severe cases Lifestyle modifications are crucial, including avoiding prolonged standing, rising slowly from lying positions, and staying well-hydrated.
Clinical Considerations
POTS is frequently associated with deconditioning, recent infections, chronic fatigue syndrome, joint hypermobility syndrome, and a spectrum of non-specific symptoms such as headache and chest pain 1. The diagnosis is made primarily on the basis of a thorough history, physical examination, and eyewitness observation, if available.
From the Research
Definition and Characteristics of Postural Orthostatic Tachycardia Syndrome (POTS)
- POTS is a form of cardiovascular autonomic disorder characterized by orthostatic intolerance and a symptomatic increase in heart rate upon standing, which can significantly impair patients' quality of life 2.
- It is an autonomic disorder characterized by an exaggerated increase in heart rate that occurs during standing, without orthostatic hypotension 3.
- POTS affects younger individuals, typically between 15-45 years old, with a distinct female predominance of approximately 80% 4.
- The prevalence of POTS ranges between 0.2% and 1.0% in developed countries 4.
Symptoms and Clinical Presentation
- Common complaints include dizziness, weakness, rapid heartbeat, and palpitation on standing 4.
- Patients often report physical deconditioning, reduced exercise capacity, headache, 'brain fog', dyspnoea, gastrointestinal disorders, and musculoskeletal pain 4.
- Symptoms can be precipitated by immunological stressors such as viral infection, vaccination, trauma, pregnancy, surgery, or psychosocial stress 4, 5.
Diagnosis and Treatment
- The golden standard for POTS diagnosis is a head-up tilt test with non-invasive beat-to-beat haemodynamic monitoring 4.
- Management typically begins with patient education and non-pharmacologic treatment options, including lifestyle modifications such as increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2, 5.
- 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, 5.
- Exercise training may be very effective and counteract deconditioning 4.