POTS (Postural Orthostatic Tachycardiac Syndrome)

Written by Andrea Whiston.

Could your patient have POTS? (Postural Orthostatic Tachycardiac Syndrome)

POTS patients will present with a structurally normal heart; however, symptoms arise from excessive pooling of blood below the level of the heart when standing upright, lower amount of blood in circulation and increased neurotransmitters released, circulating in the blood stream.

Who is affected?

This dysautonomia condition can be life altering, affecting anyone at any time, but presenting more in the female 15-50 age group, suggesting a hormonal component could be an influence. There is also an increased risk of developing POTS following a significant viral infection (e.g. mononucleosis or long Covid), and in patients with autoimmune disorders, such as Lupus, celiac disease, or Sjogren’s syndrome. Furthermore, there is a strong link between various joint hypermobility disorders, including Ehlers-Donlos syndrome and mast cell disorders. Lastly, in a small number of POTS patients, a mutation in the norepinephrine transporter gene has shows to be a factor.

Common symptoms of POTS

• Lightheaded episodes/Fainting

• Fatigue/Exhaustion

• Headaches

• Nausea

• Intolerant to increased activity

• Difficultly concentrating (brain fog)

• Palpitations

• Shortness of breath

• Chest pain

• Excessive sweating/shaking

Note, symptoms can worsen in hot environments, ie hot weather, hot bath or prolonged standing, skipping a meal or reduced salt in diet.

POTS Diagnosis

POTS can often be misdiagnosed as anxiety, panic attacks, chronic fatigue syndrome, inappropriate sinus tachycardiac, or vasovagal syncope. We have noticed an increase in POTS referrals post-Covid and have been working with this patient group to manage their challenging symptoms.

Before arriving at a POTS diagnosis, it is important to rule out what it’s not, therefore the following should be considered:

• Orthostatic hypotension - rule out dehydration

• Thyroid conditions

• Autoimmune disease such as Lupus, Sjogrens, Multiple Sclerosis

• Pheochromocytoma

There are 4 subgroups of POTS. Neuropathic, Hyperadrenergic, Hypovolemic and Secondary. A patient must meet the specific diagnostic criteria for a POTS diagnosis.

Presentation of POTS

POTS patients present with a heart rate of ≥ 30 beats per minute (bpm) or more on standing, or heart rate >120 bpm within 10 minutes upright, in the absence of orthostatic hypotension. In children and adolescents, the threshold is ≥ 40 beats per minute.

Physiological and Psychological aspect to POTS

There is both a physiological and psychological aspect to this condition.

Physical symptoms can lead to increased anxiety. Reduced exercise tolerance and diminished quality of life can impact on mental health, increasing the risk of depression. Providing a prompt assessment, appropriate support and information is important. The sooner adjustments are made to help to manage symptoms, the sooner the patient will generally start to experience an improvement in coping with their condition. POTS can last from several months to years. Due to this condition being poorly understood by the general public/employers, it can cause patients to feel isolated managing symptoms. Patients will benefit from a good support network around them.

What can be done to help reduce symptom severity?

• Specific allowances for POTS patients – e.g. increased breaks, reduced workload should be considered to help manage symptoms.

• In some cases, low FODMAP diets have shown to improve symptoms.

• Implementing a tailored exercise programme

• Medication

• Health Psychology referral for Cognitive Behavioural Therapy (CBT)

Assessment at South Island Heart

For a prompt assessment for accurate diagnosis to rule out/ confirm a POTS diagnosis you can contact us at South Island Heart to arrange for the following:

• Blood and urine testing to check for increase of Neurotransmitters

• Lying and Standing ECG

• Echocardiogram

• Ambulatory Blood Pressure monitoring

• Consult and medication review with Cardiology Specialist

• POTS Exercise advice

• Referral to a Cardiac Psychologist for additional support

• Consultation with your cardiologist

In summary

It is important to note that POTS isn’t life threatening and has a normal life expectancy with the right treatment. All treatment, including medications, should be reviewed and discussed with your cardiologist.