POTS

Definition 

Postural orthostatic tachycardia syndrome (POTS) is a condition that causes a number of symptoms when you transition from lying down to standing up, such as a fast heart rate, dizziness and fatigue. 

In a healthy person, your body’s autonomic nervous system balances heart rate and blood pressure to keep blood flowing at a healthy pace, regardless of the position that your body is in. In those with POTS, however, your body can’t coordinate the balancing of blood vessel constriction and heart rate response, meaning that your body can’t keep blood pressure steady and stable. 

Each case of POTS is different and people may see symptoms come and go over a period of years. In most cases, with treatment, a person with POTS will experience an improvement in their quality of life.

Key Statistics

• POTS is relatively common, affecting between 1 to 3 million people in the United States alone.
• By some estimates, there has been an increase of 1 million new POTS patients since pre-pandemic levels, as a result of COVID-19 and the COVID-19 vaccines
• 80% of those with POTS experience an improvement in their condition.

Causes / Risk Factors

Although further research is needed to determine the exact cause(s) of POTS, there are currently several accepted causes that are attributed to the three specific subtypes of POTS – Neuropathic, Hyperadrenergic, and Hypovolemic. Neuropathic POTS occurs when peripheral denervation (loss of nerve supply) leads to poor blood vessel muscles, especially in the legs and abdomen. Hyperadrenergic POTS is the result of an overactive nervous system. Hypovolemic POTS is caused by reduced blood volume, which can also cause similar symptoms that may overlap in neuropathic and hyperadrenergic POTS. 

• Gender and Age: Between 75 to 80% of individuals with POTS are female. The majority of those diagnosed with POTS are between 20 and 40 years old, with the average onset being 21 – diagnosis beyond the age of 40 is rare. 
• Significant illness: Viral illnesses like mononucleosis or serious infections increase your risk of POTS.
• Heavy metal poisoning

• Alcoholism

• Chemotherapy

• Type 2 diabetes
• Autoimmune conditions: People with conditions such as Sjogren’s syndrome, sarcoidosis, lupus and celiac disease are more likely to develop POTS. 
• Pregnancy

• Physical trauma

• Surgery

Symptoms & Signs

• Dizziness or lightheadedness, especially when standing up, during prolonged standing in one position or on long walks
• Fainting or near fainting
• Heart palpitations or racing heart
• Exhaustion/fatigue
• Forgetfulness and trouble focusing (brain fog)
• Nervousness or anxiety
• Shakiness 
• Excessive sweating
• Shortness of breath (dyspnea)
• Nausea and vomiting
• Exercise intolerance
• Chest pain
• Headaches
• Feeling ill
• Bloating
• Pale face and purple discoloration of hands and feet (if lower than the level of heart)
• Disrupted sleep from chest pain, racing heart rate and excessive sweating during sleep
• Situations that can trigger and/or worsen symptoms include: warm environments such as hot baths/showers or hot days, standing frequently and for long periods of time, participating in strenuous exercise, being sick (cold or infection), and menstruating.

Diet and Lifestyle Considerations for POTS

• Warm environments such as hot baths/showers or hot days can trigger and/or worsen symptoms, try to maintain a consistent temperature when possible
• Standing frequently can trigger and/or worsen symptoms
• Alcohol can worsen symptoms because it dehydrates your body
• Over-exercising or overly intense exercise can exacerbate symptoms

Integrative Treatments Overview

Integrative treatments for POTS emphasize a holistic strategy that blends lifestyle modifications with medical interventions to manage symptoms effectively. Personalized exercise routines, optimized hydration, and dietary adjustments form the core of non-pharmacological strategies, aiming to stabilize the patient’s condition through natural means. Stress reduction techniques complement these efforts by addressing the autonomic nervous system’s role. For more direct symptom management, medical compression stockings and a range of medications offer relief, while innovative approaches like nerve stimulation showcase the potential of emerging therapies. Addressing underlying health issues, particularly those related to autoimmunity, highlights the importance of a comprehensive, individualized treatment plan that considers the multifaceted nature of POTS.

Nutritional & Environmental Medicine Overview

It is recommended that a patient consult a certified practitioner to assess their symptoms and case history and explore their individual needs.  

Diagnosis and Testing

• Tilt table test (measures your heart rate and blood pressure as you change position)
• Blood and Urine Tests
• QSART (measures autonomic nerves that control sweating)
• TST (tuberculin skin test)
• Skin nerve biopsy
• Echocardiogram
• Blood volume with hemodynamic studies

Treatment

• Exercise and physical activity: Exercise is important for overall wellbeing in POTS patients and should be personalized to the patient. Often patients do better with horizontal exercises like rowing, swimming or cycling, than with upright exercise. 
• Hydration: Consuming enough water as well as the right balance of salt and electrolytes is very important. Generally, a fluid intake of two litres per day is advisable for most adults, however this should be individualized. 
• Diet and nutrition: POTS patients often benefit from eating several smaller meals rather than a few large meals, which can exacerbate symptoms. Many also experience fewer symptoms when they limit simple carbohydrates and balance their meals with increased protein, healthy fats, and complex carbohydrates. Avoiding allergenic foods and common food sensitivities also helps with symptom reduction.
• Stress reduction is key in managing POTS symptoms, so incorporating daily relaxation techniques such as breathing, gentle stretching, meditation and mindfulness practices can help. 
• Medical compression stockings can help push blood up from your legs to reduce symptoms
• Medications: Some medications may be useful in managing POTS symptoms. They include: Fludrocortisone, Pyridostigmine, Midodrine, and Beta-blockers.
• Nerve stimulation: A new clinical trial published in JACC: Clinical Electrophysiology found that stimulating the vagus nerve (a key part of the parasympathetic nervous system) could relieve POTS symptoms. Those treated with the stimulation had a significant 15-beat-per-minute reduction in rapid heartbeat after standing compared to the control group. 
• Addressing root causes: Considering the role of other underlying health issues in those with POTS, one should consider a personalized approach that addresses other health issues in patients. For example, the potential role of autoimmunity in the etiology of POTS, immunomodulatory approaches may play a role in treatment (this includes IVIG).