Is orthostatic hypotension associated with Postural Orthostatic Tachycardia Syndrome (POTS)?

From the Guidelines

Yes, orthostatic hypotension can occur alongside Postural Orthostatic Tachycardia Syndrome (POTS), though they are distinct conditions with different diagnostic criteria. According to the 2018 ESC guidelines for the diagnosis and management of syncope 1, orthostatic hypotension is characterized by a drop in blood pressure (specifically a decrease of at least 20 mmHg systolic or 10 mmHg diastolic) within 3 minutes of standing, while POTS is defined by an excessive heart rate increase (at least 30 beats per minute or exceeding 120 bpm) upon standing without significant blood pressure drop.

Some key points to consider:

• Orthostatic hypotension and POTS can coexist in some patients, with both conditions involving autonomic nervous system dysfunction affecting cardiovascular responses to positional changes 1.
• The pathophysiology of orthostatic intolerance, which includes POTS, is varied and can involve hemodynamic disturbances, including blood pressure decrease and heart rate increase 1.
• Management of patients with both orthostatic hypotension and POTS typically includes lifestyle modifications, such as increased fluid intake and salt consumption, compression garments, and gradual physical reconditioning, as well as medications like fludrocortisone, midodrine, or pyridostigmine in more severe cases.

The overlap between orthostatic hypotension and POTS occurs because both conditions involve dysfunction of the autonomic nervous system, which affects the body's ability to regulate blood pressure and heart rate in response to changes in position 1. Therefore, it is essential to consider both conditions in the diagnosis and management of patients with symptoms of orthostatic intolerance.

From the Research

Orthostatic Hypotension and POTS

• Orthostatic hypotension (OH) is defined as a sustained reduction in systolic blood pressure > 20 mm Hg or diastolic blood pressure > 10 mm Hg within 3 minutes of standing or > 60° head-up tilt 2
• Postural orthostatic tachycardia syndrome (POTS) is a chronic and often disabling disorder characterized by orthostatic intolerance with excessive heart rate increase without hypotension during upright posture 3, 4
• The pathophysiology of POTS is incompletely understood and undoubtedly multifaceted, involving a variety of mechanisms, but it does not typically include hypotension 3, 4

Relationship between OH and POTS

• POTS is characterized by orthostatic intolerance and orthostatic tachycardia without hypotension, suggesting that OH is not a typical feature of POTS 3, 4
• However, some patients with POTS may experience symptoms of cerebral hypoperfusion on standing, which can be similar to those experienced by patients with OH 2
• There is no direct evidence to suggest that OH occurs along with POTS, but both conditions can cause symptoms of orthostatic intolerance 3, 4, 2

Diagnosis and Treatment

• The diagnosis of OH requires blood pressure measurements in the supine and standing positions, while POTS is diagnosed based on excessive heart rate increase during upright posture 3, 2
• Treatment for OH typically involves nonpharmacological interventions, such as lifestyle modifications and physical countermanoeuvres, and pharmacological interventions, such as midodrine and fludrocortisone 2, 5
• Treatment for POTS typically involves patient education, non-pharmacologic treatment options, and various medications to address specific symptoms, but there are currently no FDA-approved medications for the treatment of POTS 3, 6