From the Guidelines
Postural Orthostatic Tachycardia Syndrome (POTS) is a condition characterized by an abnormal increase in heart rate when moving from a lying to standing position, with symptoms including dizziness, lightheadedness, fainting, and rapid heartbeat upon standing, and is typically treated with a combination of lifestyle modifications and medications, as outlined in the 2022 ACC expert consensus decision pathway 1.
Definition and Symptoms
POTS is a clinical syndrome usually characterized by all of the following:
- Frequent symptoms that occur with standing, such as lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue
- An increase in heart rate of ≥30 bpm during a positional change from supine to standing (or ≥40 bpm in those 12–19 y of age)
- The absence of orthostatic hypotension (>20 mm Hg reduction in systolic BP) 1
Treatment
Treatment typically involves a combination of lifestyle modifications and medications, including:
- Increasing fluid intake (2-3 liters daily) and salt consumption (5-10g daily) to address reduction in plasma volume
- Elevation of the head of one’s bed with 4–6-inch blocks during sleep
- Use of support stockings (waist-high) to ensure sufficient support of central blood volume
- Regular reclined exercise and counter-maneuvers like leg crossing when standing
- Medications such as beta-blockers (e.g., propranolol), fludrocortisone to increase blood volume, midodrine to constrict blood vessels, or ivabradine to reduce heart rate without affecting blood pressure 1
Pathophysiology
POTS occurs because the autonomic nervous system fails to properly regulate blood vessel constriction when standing, causing blood to pool in the lower extremities and the heart to beat faster to compensate 1
From the Research
Definition of Postural Orthostatic Tachycardia Syndrome (POTS)
- Postural Orthostatic Tachycardia Syndrome (POTS) is a form of cardiovascular autonomic disorders characterized by orthostatic intolerance and a symptomatic increase in heart rate upon standing, which can significantly impair patients' quality of life 2.
- POTS is defined by the development of symptoms of cerebral hypoperfusion or sympathetic activation and a sustained heart rate increment of 30 beats/min or more (40 beats/min for teenagers) within 10min of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher 3.
- POTS is a condition in which a change from a supine to an upright position causes an abnormally large increase in heart rate which may be accompanied by a variety of physical complaints 4.
Pathophysiology of POTS
- The pathophysiology of POTS is complex, multifactorial, and not completely understood, involving several mechanisms such as limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, and deconditioning 2, 3, 5.
- Three primary POTS phenotypes have been identified: hyperadrenergic, neuropathic, and hypovolemic, each requiring tailored management strategies 2, 5.
Symptoms and Comorbidities of POTS
- Common symptoms of POTS include palpitations, dyspnea, chest discomfort, and lightheadedness affecting various systems 6.
- POTS is often comorbid with other conditions such as visceral pain and dysmotility, chronic fatigue and fibromyalgia, migraine, joint hypermobility, mitral valve prolapse, and inappropriate sinus tachycardia 3.
Management and Treatment of POTS
- The objectives of POTS management are to increase the time that patients can stand, perform daily activities, and exercise, and to avoid syncope 3.
- Management involves nonpharmacologic approaches such as lifestyle modifications, including increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2, 3, 4.
- Pharmacologic therapies are primarily used to manage specific symptoms, and may include beta-blockers, pyridostigmine, fludrocortisone, midodrine, and ivabradine 2, 3, 6, 5.