What causes the exacerbation of Postural Orthostatic Tachycardia Syndrome (POTS) and increased wakefulness after a stressful event, and how long does it take for the autonomic nervous system balance to recover from the effects of adrenaline and cortisol?

From the Guidelines

After a highly stressful event, your autonomic nervous system can remain imbalanced for several days to weeks, which explains your current symptoms, and the most effective way to restore balance is to practice regular deep breathing exercises, maintain consistent sleep patterns, stay hydrated, and temporarily increase salt intake, as recommended by the most recent and highest quality study 1. The parasympathetic activation you're experiencing alongside worsened POTS (Postural Orthostatic Tachycardia Syndrome) symptoms likely represents your body's attempt to recover from the stress response while still dealing with lingering autonomic dysregulation. Some key points to consider in managing POTS and restoring autonomic balance include:

• Practicing regular deep breathing exercises, such as the 4-7-8 method, to help regulate your nervous system 1
• Maintaining consistent sleep patterns to help your body recover from the stress response 1
• Staying hydrated with 2-3 liters of fluid daily, including electrolytes, to help regulate your blood volume and blood pressure 1
• Temporarily increasing salt intake to 8-10g daily, if appropriate for your health status, to help increase blood volume and alleviate symptoms of POTS 1
• Engaging in gentle physical activity, such as walking, to help regulate your nervous system, but avoiding intense exercise until symptoms improve 1 It's also important to note that stress hormones can trigger lasting changes in autonomic regulation pathways, and people with POTS often have heightened sensitivity to these disruptions due to underlying autonomic dysfunction, as discussed in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. However, the most recent and highest quality study 1 provides the most relevant and effective recommendations for managing POTS and restoring autonomic balance. Typically, cortisol and adrenaline levels normalize within 24-72 hours after a stressful event, but the full restoration of autonomic balance can take longer, especially in people with conditions like POTS, and may require a comprehensive treatment approach that incorporates lifestyle modifications, such as those recommended in the study 1.

From the Research

Causes of Exacerbation of POTS

• Postural Orthostatic Tachycardia Syndrome (POTS) can be exacerbated by various factors, including anxiety and somatic hypervigilance 2
• Stressful events can trigger the release of adrenaline and cortisol, leading to an increase in heart rate and blood pressure, which can worsen POTS symptoms 3
• The hyperadrenergic state, which is one of the major pathophysiologic mechanisms of POTS, can contribute to the exacerbation of symptoms 3

Increased Wakefulness after a Stressful Event

• The release of adrenaline and cortisol in response to a stressful event can lead to increased wakefulness and difficulty sleeping 3
• Patients with POTS often experience sleep disturbances, including insomnia and daytime fatigue, which can be exacerbated by stressful events 4

Recovery of Autonomic Nervous System Balance

• The recovery of autonomic nervous system balance after the effects of adrenaline and cortisol can take several hours to days, depending on the individual and the severity of the stressful event 5
• Treatment with medications such as beta-blockers and pyridostigmine can help to reduce symptoms of POTS and improve autonomic nervous system function 5
• Non-pharmacological interventions, such as exercise and volume expansion, can also help to improve autonomic nervous system function and reduce symptoms of POTS 3

Time Course of Recovery

• The time course of recovery from the effects of adrenaline and cortisol can vary depending on the individual and the severity of the stressful event 5
• Studies have shown that sustained medical treatment for POTS can lead to significant improvements in symptoms and quality of life over a period of several months 5
• The exact time course of recovery is not well-established, and further research is needed to determine the optimal treatment strategies for POTS 2, 4, 3