From the Guidelines
To manage persistent Postural Orthostatic Tachycardia Syndrome (POTS) caused by a constant hyperadrenergic state, a multi-faceted approach combining nonpharmacological interventions, lifestyle modifications, and pharmacological therapies is recommended, with a focus on increasing blood volume, reducing dehydration, and alleviating symptoms. The management of POTS should prioritize nonpharmacological interventions, including salt and fluid loading, elevation of the head of the bed, and use of support stockings to address the reduction in plasma volume that follows deconditioning 1. Patients should be encouraged to drink 3 liters of water or an electrolyte-balanced fluid per day and to liberalize their sodium intake to 5-10 g per day, while avoiding factors that contribute to dehydration such as alcohol and caffeine consumption, large heavy meals, and excessive heat exposure 1. In terms of pharmacological therapies, low-dose beta-blockers such as bisoprolol, metoprolol, nebivolol, or propranolol may be used to slow the heart rate and alleviate symptoms, particularly if palpitations predominate 1. Additionally, nonselective beta-blockers like propranolol may help control debilitating symptoms in those with orthostatic intolerance and a hyper-adrenergic state, and may also be useful in those with coexisting anxiety or migraine 1. Other pharmacological options include ivabradine, fludrocortisone, and midodrine, which may be used to improve heart rate, increase blood volume, and alleviate orthostatic intolerance, respectively 1. Key aspects of the management plan include:
- Increasing fluid intake to 3 liters per day
- Liberalizing sodium intake to 5-10 g per day
- Using support stockings and elevating the head of the bed
- Avoiding dehydration-causing factors
- Considering pharmacological therapies such as beta-blockers, ivabradine, fludrocortisone, and midodrine
- Implementing a formalized exercise program, which may be supervised or done at home, to support long-term cardiovascular health 1.
From the Research
Managing Persistent Postural Orthostatic Tachycardia Syndrome (POTS)
Caused by a Constant Hyperadrenergic State
To manage persistent POTS caused by a constant hyperadrenergic state, several strategies can be employed:
- Lifestyle modifications, including increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2
- Pharmacologic therapies, such as beta-blockers, to manage specific symptoms, particularly in hyperadrenergic POTS 2
- Identification and differentiation of hyperadrenergic POTS from neuropathic POTS, as patients with hyperadrenergic POTS are usually difficult to treat and require tailored management strategies 3
Non-Pharmacological Interventions
Non-pharmacological interventions, such as:
- Chronic volume expansion via sleeping in the head-up position
- Reduction in venous pooling during orthostasis by lower body compression garments extending at least to the xiphoid or with an abdominal binder
- Physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, negative-pressure breathing, etc. may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients 4
Exercise and Physical Reconditioning
Exercise and physical reconditioning, particularly horizontal exercise (e.g., rowing, swimming, recumbent bike, etc.) at the beginning, can help improve functional capacity and manage POTS symptoms 4 As patients become increasingly fit, the duration and intensity of exercise should be progressively increased, and upright exercise can be gradually added as tolerated 4
Treatment Approaches
Treatment approaches for hyperadrenergic POTS may include: