Postural Orthostatic Tachycardia Syndrome (POTS)

Standing up every morning is perhaps one of the most basic actions we take. Most people stand up without a second thought, but for some, it can bring a host of symptoms from dizziness to brain fog to a general feeling of illness. Eventually, they may be diagnosed with a condition called postural orthostatic tachycardia syndrome, or POTS. 

What is postural orthostatic tachycardia syndrome?

Postural orthostatic tachycardia syndrome is a dysautonomia condition, which means the body’s autonomic nervous system (ANS) is malfunctioning. The ANS regulates aspects of the body we don’t have to think about, like breathing. Normally, the ANS coordinates an even flow of blood by adjusting heart rate and blood pressure. In people with POTS, that automatic adjustment isn’t working. 

This malfunction plays out in the most common and telling symptom of POTS — issues when standing. When you stand, blood tends to pool in the lower extremities. If working correctly, the autonomic nervous system sends out hormones that tighten the blood vessels, which pushes more blood to the heart and brain. When the body is unable to coordinate these adjustments, tachycardia, or a heart rate over 100 beats per minute, occurs. 

While doctors aren’t certain what causes POTS, sometimes it begins after a major life event. These include viral illness, pregnancy, major surgery, and physical trauma. Some studies have linked an increase in POTS cases to those who have had a SARS-CoV-2 (COVID-19) infection.

What are some of the symptoms?

Symptoms of POTS occur when you transition from lying down to standing. Additionally, the longer someone is upright, the more the blood pools. Standing for long periods of time may also be difficult to tolerate for people with this condition.

Symptoms are wide ranging, vary from person to person, and can include:

  • Dizziness
  • Fatigue
  • Fainting
  • Heart palpitations 
  • Shakiness
  • Brain fog
  • Chest pain
  • Feeling sick
  • Anxiety
  • Bloating 
  • Disrupted sleep

Why is it sometimes challenging to diagnose POTS?

POTS symptoms vary, and they also change over the course of time. Environmental triggers may bring on more severe symptoms, and sometimes symptoms can subside for long periods of time before reemerging. Additionally, POTS is not a condition that is well known by all doctors, and there is no definitive lab test for POTS. Patients sometimes go several years before an accurate diagnosis is made. 

In order to diagnose POTS, doctors commonly use a tilt table test, during which they take vital signs both lying down and after standing for a period of time. Other assessments used include echocardiograms, tests of the autonomic nervous system, and tests on blood volume. 

What is the role of cardiologists and electrophysiologists?

POTS is a disorder of the autonomic nervous system, the part of the body that regulates involuntary bodily functions. It is a disorder that reaches wider than just the heart, but cardiologists and electrophysiologists can play a key role in treating POTS. 

Electrophysiologists specialize in treating the heart’s electrical system, which coordinates and regulates the heartbeat. They have become experts in treating the symptoms of POTS. Though there is no cure for POTS, medical treatment and recommendations for lifestyle changes can improve quality of life for those living with POTS. Cardiologists are also qualified to diagnose and treat POTS. Their major role after diagnosis is to help patients understand the disorder and work with them to find ways to improve their quality of life.

How is POTS treated?

There is no cure for POTS, but often lifestyle changes can bring an improvement in symptoms. The three main recommendations for patients are an increase in sodium intake, wearing compression garments, and gradually stepping up exercise. Exercise must be approached gradually so that it does not trigger dizziness or fainting. 

Over time, patients are encouraged to note their particular triggers, which can include skipping meals or sleep and warm, moist environments. When those triggers cannot be avoided, patients learn to take steps to manage potential symptoms.

There are no medications that are approved by the FDA to treat POTS specifically; however there are several that doctors prescribe for off-label use. They include beta blockers to slow the heart rate, midodrine to help blood vessels constrict, and fludrocortisone to help kidneys retain water.