Does Postural Orthostatic Tachycardia Syndrome (POTS) usually present first or Chronic Fatigue Disorder (CFD)?

From the Guidelines

POTS (Postural Orthostatic Tachycardia Syndrome) typically presents before CFD (Chronic Fatigue Disorder) in most patients, as the autonomic nervous system dysfunction in POTS can lead to decreased cerebral perfusion, poor exercise tolerance, and deconditioning, eventually manifesting as chronic fatigue. POTS is characterized by an abnormal increase in heart rate upon standing, accompanied by symptoms like lightheadedness, palpitations, and fatigue 1. Many patients initially experience these orthostatic symptoms and cardiovascular dysregulation before developing the more pervasive fatigue and post-exertional malaise characteristic of CFD.

Key Points to Consider

• The relationship between POTS and CFD is complex, and some patients may experience fatigue symptoms concurrently with or even before their orthostatic symptoms become apparent 1.
• The underlying pathophysiology involves dysregulation of the autonomic nervous system, affecting blood vessel constriction and heart rate control, which explains why cardiovascular symptoms often precede the more generalized fatigue symptoms 1.
• Recent studies have explored various treatment options for POTS and CFD, including pharmacological and non-pharmacological approaches 1.
• It is essential to prioritize the treatment of POTS symptoms, as they can have a significant impact on the patient's quality of life and morbidity 1.

Treatment Considerations

• Treatment options for POTS may include pharmacological agents such as β-blockers, pyridostigmine, fludrocortisone, and midodrine, as well as non-pharmacological approaches like increasing salt and fluid intake, intravenously administered salt, and compression stockings 1.
• For CFD, treatment options may include pacing, cognitive behavioral therapy, and graded exercise therapy, although these should be approached with caution and individualized to the patient's needs 1.

From the Research

Presentation of Postural Orthostatic Tachycardia Syndrome (POTS) and Chronic Fatigue Disorder (CFD)

• The relationship between the onset of POTS and CFD is complex, with some studies suggesting that CFD may precede the development of POTS 2, 3.
• A study published in 2019 found that 41% of recumbent CFS subjects and 72% of standing CFS subjects experienced dizziness and lightheadedness, indicating that orthostatic intolerance is a significant problem in CFS 2.
• Another study published in 2022 found that 60% of ME/CFS patients had an abnormal physiologic response to orthostatic challenge, with hypocapnia being the most frequent abnormality, followed by postural orthostatic tachycardia 3.
• POTS is often characterized by excessive heart rate increase upon standing, and its pathophysiology is complex and multifactorial 4, 5, 6.
• The onset of POTS may be precipitated by immunological stressors such as a viral infection, and a typical patient with POTS is a female of child-bearing age, who often first displays symptoms in adolescence 5.

Comorbidities and Overlapping Symptoms

• CFD and POTS often have overlapping symptoms, including fatigue, exercise intolerance, and gastrointestinal distress 5.
• Anxiety and somatic hypervigilance play significant roles in POTS, and common comorbidities include visceral pain and dysmotility, chronic fatigue and fibromyalgia, migraine, joint hypermobility, mitral valve prolapse, and inappropriate sinus tachycardia 6.
• 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 5.