From the Guidelines
For patients with Postural Orthostatic Tachycardia Syndrome (POTS), I strongly recommend a comprehensive treatment approach that prioritizes lifestyle modifications and medications to alleviate symptoms and improve quality of life, as outlined in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
Key Components of POTS Treatment
- Increasing fluid intake to 2-3 liters daily and sodium consumption to 8-10 grams per day to expand blood volume
- Wearing compression garments (30-40 mmHg) on the lower extremities to reduce blood pooling
- Beginning a gradual, reclined exercise program focusing on strengthening leg muscles
- Medications such as beta-blockers (e.g., propranolol 10-20mg twice daily or metoprolol 25-50mg twice daily) to reduce heart rate, midodrine (2.5-10mg three times daily, not after 6pm) to increase blood pressure, and fludrocortisone (0.1-0.2mg daily) to aid in sodium and fluid retention
Rationale for Treatment Approach
The pathophysiology of POTS is varied, but treatments that improve symptoms might decrease the occurrence of syncope, although this is unknown 1. The Heart Rhythm Society consensus statement provides further guidance on the management of POTS 1.
Monitoring and Adjusting Treatment
Regular monitoring of vital signs and symptoms is crucial to adjust treatment as needed. By addressing the autonomic nervous system dysfunction that causes blood to pool in the lower body upon standing, these treatments aim to reduce cardiac output and compensatory tachycardia, ultimately improving morbidity, mortality, and quality of life for patients with POTS.
From the Research
Treatment Approaches for POTS
- Lifestyle modifications are the first-line treatment for all patients, including increased fluid and salt intake, compression garment use, physical reconditioning, and postural training 2
- Pharmacologic therapies are used to manage specific symptoms, with limited evidence supporting their efficacy 2
- Beta-blockers are an effective option for hyperadrenergic POTS, which is characterized by excessive norepinephrine production or impaired reuptake 2
- Agents that enhance vascular tone, such as pyridostigmine and midodrine, are used to treat neuropathic POTS, which results from impaired vasoconstriction during orthostatic stress 2, 3
- Volume expansion and exercise are the primary treatments for hypovolemic POTS, which is often triggered by dehydration and physical deconditioning 2
Medications Used in POTS Treatment
- Pyridostigmine has been shown to improve symptoms of orthostatic intolerance in some patients with POTS, with a response rate of 43% in one study 4
- Midodrine is used to treat neuropathic POTS, and has been shown to improve symptoms in some patients 3
- Beta-blockers, such as propranolol, are used to treat hyperadrenergic POTS, and have been shown to improve symptoms in some patients 3
- Fludrocortisone is used to treat hypovolemic POTS, and has been shown to improve symptoms in some patients 3, 5
Experimental Therapies for POTS
- Cardiac neuromodulation is a promising experimental therapy for POTS, although more research is needed to fully understand its effects 5
- Supplemental therapies such as iron, vitamin D, and α lipoic acid may be useful in some patients with POTS, although more research is needed to fully understand their effects 5
- Erythropoietin, IVIG, and desmopressin are more specialized and nuanced alternatives for treating POTS, although more research is needed to fully understand their effects 5