From the Guidelines
The worsening of POTS symptoms the day after stress and anxiety is likely due to the prolonged effects of stress hormones on the autonomic nervous system, and management should focus on consistent hydration, compression garments, gentle exercise, stress management, and potentially medications like beta-blockers or fludrocortisone, as recommended in the 2022 ACC expert consensus decision pathway 1. The pathophysiology of POTS is complex and likely heterogeneous, involving deconditioning, immune-mediated processes, excessive venous pooling, and a hyperadrenergic state, as noted in the 2018 ESC guidelines for the diagnosis and management of syncope 1. Key factors that contribute to the worsening of POTS symptoms after stress and anxiety include:
- Prolonged effects of stress hormones, such as cortisol and adrenaline, which can remain elevated for 24-48 hours and affect blood vessel constriction and heart rate regulation
- Disruption of sleep quality, leading to fatigue and exacerbation of POTS symptoms
- Muscle tension and dehydration, which can independently worsen POTS symptoms
- Potential "rebound effect" where the initial sympathetic activation is followed by autonomic instability rather than proper parasympathetic recovery To manage POTS symptoms, the following strategies are recommended:
- Consistent hydration with electrolytes (2-3 liters daily)
- Compression garments to help improve blood flow and reduce symptoms
- Gentle reclined exercise to improve cardiovascular function and reduce deconditioning
- Stress management techniques, such as deep breathing or meditation, to help reduce stress and anxiety
- Medications, such as beta-blockers (e.g., propranolol 10-20mg) or fludrocortisone, which may help alleviate symptoms, but require physician supervision, as noted in the 2022 ACC expert consensus decision pathway 1.
From the Research
Pathophysiology of POTS
- POTS is a heterogeneous syndrome caused by several pathophysiologic mechanisms, including limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, and deconditioning 2, 3.
- These mechanisms can lead to an increase in heart rate and symptoms of orthostatic intolerance, such as cerebral hypoperfusion and fatigue.
Role of Anxiety in POTS
- Anxiety and somatic hypervigilance play significant roles in POTS, and patients with POTS often exhibit high levels of anxiety 2, 4.
- However, studies have shown that POTS patients do not exhibit signals of anxiety disorders more often than control groups when questionnaires without autonomic items are used 4.
- This suggests that the anxiety experienced by POTS patients may be a concomitant phenomenon of orthostatic stress rather than a separate anxiety disorder.
Worsening of POTS Symptoms
- The worsening of POTS symptoms the day after a stressful and anxiety-filled day may be due to the hyperadrenergic state and increased sympathetic activity that occurs in response to stress and anxiety 3, 5.
- This increased sympathetic activity can lead to an increase in heart rate and worsening of POTS symptoms, despite the expected increase in parasympathetic response.
- Treatment with beta-blockers, such as propranolol, has been shown to attenuate tachycardia and improve symptoms in POTS patients 5, 6.