Postural Orthostatic Tachycardia Syndrome (POTS)

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What is Postural Orthostatic Tachycardia Syndrome (POTS)?

Postural orthostatic tachycardia syndrome (abbreviated as POTS) is a condition in which the heart rate becomes inappropriately fast (tachycardia) when going from a lying to standing position. Simply going from lying down to standing causes the heart rate to jump up 30 beats per minute or more, and it occurs within 10 minutes of standing. Blood pressure does not drop during these episodes, which separates it from another condition called orthostatic hypotension. About 1/3 of people may faint during some of these episodes. Frequently, POTS is also associated with headaches and blue-tinging of the skin on the extremities. Many people often experience sleep disturbances as well.

POTS is subdivided into different categories, depending on the mechanisms by which the tachycardia occurs. These subtypes often overlap, however, and many people fall into multiple categories of POTS. Hyperadrenergic POTS occurs when adrenaline levels rise while standing. This causes the heart rate to rise.

Another type is called neuropathic POTS. This occurs due to pooling of blood in the legs, which creates “low volume” effect on the body. When the body senses low blood volume, it tries to compensate by increasing the heart rate. Neuropathic POTS probably occurs because blood pools in the legs from inappropriate constriction of the veins returning to the heart.

Sometimes POTS occurs due to other conditions, like diabetes, intestinal disorders, autoimmune disorders, cancer, and connective tissue abnormalities. This subcategory is called secondary POTS because it happens due to other concurrent health conditions, rather than as a primary issue on its own.

There appear to be multiple factors in the development of POTS, but it occurs more commonly i

Common Symptoms

The symptoms of POTS are usually triggered by moving from a lying to standing position, however there can be other symptoms that are not necessarily dependent on this event. The most common symptoms of POTS are:

Dizziness/lightheadedness after standing
Heart palpitations
Sweating
Nausea/vomiting
Blurry vision
Cloudy/foggy thinking
Disturbed sleep
Feeling chronically fatigued
Chest pain
Headaches/migraines
Anxiety
Blue discoloration of extremities
Diarrhea or constipation

Diagnosis

There are many different conditions which can resemble POTS, which can make it somewhat difficult to diagnose. A major test for POTS involves simply moving a patient from the lying position to a standing position and monitoring their heart rates. This is accomplished by strapping them to a table (called a tilt table) capable of rotating between a horizontal and vertical position and monitoring heart rate and blood pressure during the transition.

There are usually other tests that are performed in addition to the tilt table, however. Other diagnostics commonly performed include:

Bloodwork: This can help rule out anemia, dehydration, low blood sugar, or electrolyte disorders which can resemble POTS
Echocardiogram: This is an ultrasound of the heart to make sure a primary heart problem is not causing fainting or elevated heart rates
Electrocardiogram (ECG or EKG): This is a test for arrhythmias which may resemble POTS in some circumstances
Autonomic Breathing Test: This test measures heart rates and blood pressure during activity.
QSART: This is another test of the autonomic nervous system, specifically of the nerves responsible for controlling sweat glands.
24-Hour Urine Collection: This test is meant to measure the amount of sodium excreted in the urine. Many people with POTS have low levels of sodium in their urine.
Infectious disease testing: Many diseases are associated with POTS, including mononucleosis and Lyme disease.

A diagnosis of POTS also requires certain criteria, which are as follows:

An increase in heart rate of at least 30 beats per minute following the transition from lying down to standing
- For people under 20 years of age, this increase must be greater than 40 beats per minute
Symptoms have lasted for more than 6 months
Symptoms worsen when standing and improve when lying down
No other conditions which would explain the observed symptoms

Treatment Options

Treatment for POTS is usually multi-modal, and includes simple approaches such as drinking more water, supplement salt, but also sometimes medications. All of these medications are used in an “off-label” manner, meaning that they have not been specifically approved for use in POTS, but some clinicians find that they provide benefits.

Pharmaceuticals:

Beta blockers: These medications prevent the heart rate from speeding up inappropriately by blocking the effects of adrenaline on the heart.
Ivabradine: This is another cardiac medication which can help control the heart rate by preventing it from becoming too fast.
Pyridostigmine: This medication blocks the enzyme which breaks down acetylcholine, a neurotransmitter in the body. Pyridostigmine is usually prescribed for the neuromuscular condition myasthenia gravis, but it appears to help some people with POTS.
Midodrine: This medication works by raising the blood pressure. It has been approved for use in people with dysautonomia and those with orthostatic hypotension. It does however carry the risk of increasing blood pressure while lying down, and so it should only be taken early in the day and not before bed.
Fludrocortisone: This is a corticosteroid which may help improve the body’s regulation of sodium. People suffering from POTS often have low sodium levels, and this medication may help retain sodium and improve blood volume.
Anti-depressant Medications: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) seem to be helpful in a subset of people with POTS. Serotonin plays a role in regulation of heart rate and blood pressure, and these medications may help improve or normalize serotonin’s role in this process.
Desmopressin: This is a synthetic form of anti-diuretic hormone, the hormone secreted by the pituitary gland which is responsible for preventing inappropriate loss of water. This increases circulating blood volume by causing water retention.
Erythropoietin: This is a hormone that stimulates the production of red blood cells. This is another strategy to increase circulating blood volume.
Methyldopa: Lowers the heart rate and blood pressure through effects on the central nervous system.
Octreotide: This causes constriction of blood vessels in the abdomen, possibly improving venous return to the heart.
Antibiotics/Antimicrobials: If your condition is related to an infectious agent such as Lyme disease, antibiotics may be warranted.

Non-pharmaceutical options:

There are many non-pharmaceutical options for POTS.

Increase water intake: Low circulating blood volume is often a component of POTS. Increasing water intake to 8 to 10 cups a day. It is important to begin drinking water shortly after waking.
Increase salt intake: Low sodium levels are frequently associated with POTS and can result in decreased circulating blood volume. Salt intake can be increased by adding salt to food, taking sodium supplements, or consuming sports drinks.
Eat small meals: Smaller, more frequent meals can improve symptoms for many people.
Avoid foods which cause diuresis: This includes alcohol and caffeine, which both cause loss of water and may worsen POTS.
Aerobic Exercise: Aerobic exercise has been shown to improve POTS symptoms in many people. If needed, exercise in positions in which you are seated if fainting or light-headedness is an issue.
Yoga: Yoga decreases total body inflammation and improves strength of core muscles, improves lung capacity, and is overall good for the cardiovascular system. Many POTS sufferers find that incorporating yoga into their lives greatly helps their symptoms.
Compression Socks/Tights: These products help prevent blood from pooling in the legs and increase the return of blood to the heart when standing/moving.
Dietary Modifications: Eliminating processed foods and avoiding large changes in blood sugar levels is helpful for people with POTS. Focus on eating a balanced diet with low-glycemic foods like vegetables, berries, and apples. Increase your intake of omega-3 and omega-6 fatty acids which are important for neural healthy.
Probiotics: Intestinal health is important for regulating systemic inflammatory responses and reducing loss of water. Taking a probiotic will help regulate intestinal health and prevent unnecessary water loss.
Acupuncture: Acupuncture can be a very helpful component of treating POTS.
Grounding: Also called “Earthing,” grounding is the concept that our bodies can exchange electrons with the surface of the earth. Rubber-soled shoes insulate us from this exchange. By walking barefoot allows this exchange to take place and some POTS suffers report that this strategy has been helpful in management of their condition.
Myofascial Release: Massage or simply using the pressure of your body against a tennis ball can help relax the body, lower heart rate, and improve blood flow.
Epsom Salt Baths: These are good for exchanging toxins from the body while allowing magnesium across the skin. Magnesium is important for may metabolic processes in the body and is an important part of cardiovascular and neuronal health and may help improve sleep quality in people with POTS.
Far Infrared Waves: Far infrared waves penetrate the body and dilate blood vessels, improving cardiovascular flow.
Pulsed Electromagnetic Frequency (PEMF): This may improve oxygenation, reduce pain and inflammation, and improve energy.
Biofeedback: This approach teaches the brain to control physiologic changes by responding to them when they occur.
Chelation therapy: Some cases of POTS may be due to heavy metal toxicity. Chelation with EDTA or other metal-binding compounds may be helpful.
Counter-Maneuvers: This involves tensing muscles or crossing the legs in response to the elevations in heart rates and dizziness which occur. This can help improve return of blood to the heart and reduce severity of symptoms.
Mold Binding Agents: If your POTS symptoms are related to mold toxicity or exposure, these treatments can help rid the body of toxins:
- Cholestyramine (CSM): This is a binding agent which is labeled for lowing cholesterol, but however it may be used “off-label” to remove biotoxins from the body as well.
- Apple pectin: Derived from apples, this natural product can be a good option for those with sensitive GI tracts.
- Activated charcoal: A highly absorbent compound, activated charcoal can be used as part of many “detox” protocols and also may be helpful in removing biotoxins from the body.
Supplements:
- Quinton Marine Plasma: Seawater which contains high levels of electrolytes and nutrients. This can be a good source of salt, magnesium, and other nutrients for the body.
- Coenzyme Q10: A powerful antioxidant important to both cardiovascular and neuronal health.
- L-carnitine: An amino acid important for cellular metabolism and cardiovascular health.
- Ashwagandha: A natural adaptogen, this can prevent adrenal fatigue which seems to occur in many people with POTS.
- Zinc sulfate: Zinc is important for immune function. Immune system dysregulation is often associated with POTS; zinc sulfate can help improve immune system and health and help it respond to viruses and other infections associated with POTS.
- Licorice Root: This is an antimicrobial compound which may help the body recover from many of the triggers of POTS. Licorice root also supports adrenal health.
- Lemon Balm: In addition to being a calming herb, lemon balm also is antimicrobial and can help the body recover from some of the viral causes of POTS.
- Vitamin C: An important antioxidant and useful for immune health as well as health of connective tissues.
- Sodium and potassium supplementation: Sometimes increasing dietary consumption isn’t enough or is difficult for some people. Taking a supplement can help.
- Alpha lipoic acid: Supports nervous system health and may help counter some of the “brain fog” which can occur.
- Omega-3 and Omega-6 fatty acids: Fish or krill oil can help provide these good fats which support immune, cardiovascular, and neurologic health while being anti-inflammatory in nature.

Prevention

There is no known way to prevent POTS from starting, however living a healthy lifestyle with lots of exercise and a healthy well-balanced diet may reduce your own personal risk. Many cases of POTS seem to be associated with other health issues. These issues can range from autoimmune disorders, immune dysregulation, infectious diseases, or endocrine diseases. The risks of many of these conditions can be minimized through healthy, clean living. By preventing the associated conditions, you may be able to prevent or reduce the risk of POTS occurring.

For those who already suffer from POTS, symptoms can often be managed by staying hydrated and avoiding over-exertion or overheating. Drink plenty of water from waking to the end of the day is important. If low sodium levels are an issue for you, drink electrolyte-rich drinks or increase your sodium intake through diet or supplement. Get plenty of rest. Many people find that sleeping with their head elevated improves sleep quality and reduces symptoms.

Besides staying hydrated and getting plenty of rest, regular exercise often becomes a cornerstone of minimizing the symptoms of POTS. Start with slow, easy exercises for a few minutes a day to build strength and stamina, and work up to 30 minutes of aerobic exercise several times a week. Exercise retrains the nervous system and improves blood flow while increasing overall energy.

Causes

The cause of POTS is often a mystery, but it is often associated with a previous illness, surgery, or pregnancy. The common mechanisms appear to be dysregulation of the autonomic nervous system or poor regulation of sodium and water levels in the body. This may be due to “retraining” of the nervous system with prolonged bed rest, making it respond inappropriately during periods of standing.

Approximately half of POTS cases are associated with viral infections, including Epstein-Barr virus (mononucleosis), influenza, or viral gastroenteritis (such as norovirus). Many people who suffer from POTS also suffer from chronic fatigue syndrome, which is also often associated with these viral infections.

Lyme disease is another infectious agent that has been implicated in POTS. Lyme disease is a tick-borne disease which can manifest in many different ways. Like the viral diseases listed above, Lyme disease often causes vague symptoms, but has been implicated as an agent capable of causing POTS as well as general dysregulation of the immune system.

Immune dysregulation can eventually result in autoimmune disorders and another condition called Mast Cell Activation Syndrome (MCAS), a disorder in which a type of immune cell called a mast cell spontaneously and inappropriately releases compounds used in the immune response. These cells contain, in addition to other compounds, histamine. Histamine causes dilation of the blood vessels and can cause a sudden drop in blood pressure as well as increase in heart rate. POTS sufferers often also suffer from MCAS. This condition is also often associated with a connective tissue disorder called Ehlers-Danlos syndrome, a genetic condition. There are appears to be a connection between these three diseases, as many people with Ehlers-Danlos syndrome suffer from all three conditions. Genetic mutations have been associated with POTS as well, meaning some people are likely predisposed even in the absence of some risk factors such as viral infections.

Dysautonomia is another condition which appears to be closely linked to POTS. Dysautonomia is general inappropriate function of the portion of the nervous system responsible for maintain blood pressure and doing automatic processes such as digestion, maintaining core body temperatures, and maintaining heart rate and blood pressure. Dysautonomia is also associated with a variety of other conditions, and some types of dysautonomia may play a role in POTS.

Cancerous processes are also capable of causing POTS as part of a paraneoplastic syndrome (that is, disease process that is occurring due to cancer).

Chronic toxic exposures which affect the nervous system are also capable of causing POTS. This can include thing such as mold, heavy metal toxicities as well as chronic alcoholism or drug abuse. Mold exposure in particular has been linked to POTS for many people, and it is very common in older homes and buildings. People who live in climates which favor the development of mold may be particularly at risk. Exposure to industrial chemicals, pesticides, or other pollutants may also play a role in the development of POTS.