Postural orthostatic tachycardia syndrome: Difference between revisions

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'''Postural orthostatic tachycardia syndrome''' aka '''POTS''' aka '''postural tachycardia syndrome''' is a condition in which a change from the supine position (lying horizontally) to an upright position causes an abnormally large increase in heart rate, called [[tachycardia]]. Other symptoms of an orthostatic nature — occurring in response to upright posture — may accompany the [[tachycardia]].<ref>[https://www.ncbi.nlm.nih.gov/pubmed/24982638 Neuronal and hormonal perturbations in postural tachycardia syndrome]</ref> It is a form of [[orthostatic intolerance]] (OI). Accompanying the heart rate acceleration, other symptoms, such as headaches, fatigue, sweating, nausea, fainting and dizziness may occur. POTS is associated with an increase in heart rate from the lying to upright position of greater than 30 beats per minute, or a heart rate of greater than 120 beats per minute within 10 minutes of standing.<ref>http://www.potsuk.org/</ref>
'''Postural orthostatic tachycardia syndrome''' ('''POTS''', or '''postural tachycardia syndrome)''' is a condition in which a change from the supine position (lying horizontally) to an upright position causes an abnormally large increase in heart rate, called tachycardia. It is a form of [[orthostatic intolerance]] (OI), a type of [[dysautonomia]], which means a dysregulation of the [[autonomic nervous system]] (ANS). The [[autonomic nervous system]] controls those functions of the body that are considered automatic and involuntary, such as heart rate, blood pressure, respiration, digestion, and arousal. Other symptoms of an orthostatic nature — occurring in response to upright posture — typically accompany the tachycardia.<ref>{{Cite journal | last = Mar | first=Philip L. | last2 = Raj | first2 = Satish R. | date = 2014 | title=Neuronal and hormonal perturbations in postural tachycardia syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/24982638|journal=Frontiers in Physiology|volume=5|pages=220|doi=10.3389/fphys.2014.00220|issn=1664-042X|pmc=|pmid=24982638|via=}}</ref> These include, but are not limited to [[Headache|headaches]], [[fatigue]], [[Excessive sweating|sweating]], [[nausea]]; [[fainting]] and [[dizziness]]. The female to male ratio of patients with POTS is 4:1.<ref>{{Cite news | url=http://www.potsuk.org/ | title = PoTS - Postural Tachycardia Syndrome | last = | first = |work=PoTS UK|access-date=2018-08-16|language=en | date = |archive-url=|archive-date=|url-status=}}</ref><ref>{{Cite news | url=http://www.potsuk.org/what_is_pots2 | title = PoTS - Postural Tachycardia Syndrome - What is POTS? | last = | first = |work=PoTS UK|access-date=2018-08-16|language=en | date = |archive-url=|archive-date=|url-status=}}</ref>


=Signs and symptoms=
== Onset ==
Onset may be linked to infection including viruses like EBV or enteroviruses, trauma, [[surgery]] or stress.<ref>{{Cite journal | last = Grahame | first = Rodney | last2 = Kirbis | first2 = Mojca | last3 = Andrew P. Owens | last4 = Iodice | first4 = Valeria | last5 = Low | first5 = David A. | last6 = Mathias | first6 = Christopher J. | date = Jan 2012 | title = Postural tachycardia syndrome—current experience and concepts|url=https://www.nature.com/articles/nrneurol.2011.187|journal=Nature Reviews Neurology|language=en|volume=8|issue=1|pages=22–34|doi=10.1038/nrneurol.2011.187|issn=1759-4766}}</ref><ref name=":4">{{Cite journal | last = Gunning | first = William T. | author-link = | last2 = Kvale | first2 = Heather | authorlink2 = | last3 = Kramer | first3 = Paula M. | authorlink3 = | last4 = Karabin | first4 = Beverly L. | authorlink4 = | last5 = Grubb | first5 = Blair P. | authorlink5 =  | date = 2019-09-17 | title = Postural Orthostatic Tachycardia Syndrome Is Associated With Elevated G‐Protein Coupled Receptor Autoantibodies|url=https://www.ahajournals.org/doi/full/10.1161/JAHA.119.013602|journal=Journal of the American Heart Association|volume=8|issue=18| pages = e013602|doi=10.1161/JAHA.119.013602|pmc=|pmid=|access-date=|quote=|via=}}</ref>


=Testing=
==Signs and symptoms==
Assessing orthostatic blood pressure can be done in a physician's office by measuring the patient's blood pressure while lying down, sitting, and standing at standardized time increments. Dr. [[Lucinda Bateman]] uses a modified orthostatic blood pressure assessment called the [[NASA 10-minute Lean Test]], a variant of a test used by NASA researchers to test for orthostatic intolerance following space flight. The NASA 10-minute Lean Test in less taxing on the patient and can be done in any physician's office. Instructions are available for printout for both [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Test-Instructions-1.pdf healthcare providers] and [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Patient-Preparation-Instructions-1.pdf patients].<ref>https://batemanhornecenter.org/assess-orthostatic-intolerance/</ref>
[[File:Acrocyanosis-in-POTS.jpg|thumb|[[wikipedia:Acrocyanosis|Acrocyanosis]] in POTS. These images shows the legs of two patients with POTS, immediately after standing up and after standing for several minutes. The reddish-purple discoloration in the legs is very notable, due to poor circulation in the extremities, which returns to normal upon returning to a reclined position.Source: Abou-Diab, J., Moubayed, D., Taddeo, D., Jamoulle, O., & Stheneur, C. (2018). Acrocyanosis Presentation in Postural Orthostatic Tachycardia Syndrome. International Journal Of Clinical Pediatrics, 7(1-2), 13-16. License: CC-BY-NC 4.0]]
The main symptom of POTS is an abnormal increase in heart rate upon standing. The specific diagnostic criteria for POTS is an increase in heart rate from the lying to upright position of greater than 30 beats per minute, or a heart rate of greater than 120 beats per minute within 10 minutes of standing. There needs to be an absence of significant orthostatic hypotension (magnitude of blood pressure drop ≥ 20/10 mm Hg) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8920526/. Patients with POTS usually present with other symptoms, commonly occurring in the upright position. These include:
* [[Hypovolemia]] (low blood volume)
* High levels of plasma [[norepinephrine]] when standing
* [[Dizziness]]/lightheadedness and [[syncope]] (fainting)
* [[Headache]]s and [[migraine]]s
* [[Cognitive impairment]] / [[brain fog]]
* [[Heart palpitation]]s
* [[Chest pain]]
* [[Dyspnea|Shortness of breath]]
* [[Sleep abnormalities]]
* [[Pain#Neuropathic_pain|Neuropathic pain,]] Coldness or pain in the extremities
* [[Small fiber neuropathy#Small_fiber_polyneuropathy|Small fiber polyneuropathy]] (in 50% of patients)
* [[Fatigue]]
* [[Exercise intolerance]]
* [[Nausea]]
* Tremulousness (shaking)
* [[Acrocyanosis]]-- reddish purple discoloration in the legs, due to poor circulation in the extremities, which returns to normal upon returning to a reclined position
* [[Light sensitivity|Sensory sensitivity]]
* [[Abdominal pain]], [[gastroparesis]], or [[rapid gastric emptying]]
* Elevated [[sympathetic tone]]<ref name=":4" /><ref>{{Cite web|url=http://standinguptopots.org/learning/pots-symptoms | title = Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS) | last = | first = | date = July 9, 2018 | website = Standing Up to POTS|archive-url=|archive-date=|url-status=|access-date=}}</ref><ref>{{Cite journal | last = Raj | first = Satish R | date = 2006-04-01 | title = The Postural Tachycardia Syndrome (POTS): Pathophysiology, Diagnosis & Management|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1501099/|journal=Indian Pacing and Electrophysiology Journal|volume=6|issue=2 | pages = 84–99|issn=0972-6292|pmc=1501099|pmid=16943900}}</ref><ref name=":1">{{Cite web|url=http://www.dysautonomiainternational.org/page.php?ID=30 | title = Dysautonomia International: Postural Orthostatic Tachycardia Syndrome|website=dysautonomiainternational.org|language=en|access-date=2018-10-25}}</ref>
Common stimuli in daily life, such as modest [[exercise|exertion]], food ingestion and heat, can exacerbate symptoms.<ref name=":3">{{Cite journal | last = Grahame | first = Rodney | last2 = Kirbis | first2 = Mojca | last3 = Andrew P. Owens | last4 = Iodice | first4 = Valeria | last5 = Low | first5 = David A. | last6 = Mathias | first6 = Christopher J. | date = Jan 2012 | title = Postural tachycardia syndrome—current experience and concepts|url=https://www.nature.com/articles/nrneurol.2011.187|journal=Nature Reviews Neurology|language=en|volume=8|issue=1|pages=22–34|doi=10.1038/nrneurol.2011.187|issn=1759-4766}}</ref>


If the results of the standard orthostatic blood pressure assessment are inconclusive, a [[tilt table test]] can be used for diagnosis.<ref>http://myheart.net/pots-syndrome/diagnosis-tests/</ref>
== Potential mechanisms ==
Autoimmunity is thought to play a role in many cases of POTS: adrenergic<ref>{{Cite journal | last = Kem | first = David C. | last2 = Melander | first2 = Olle | last3 = Sutton | first3 = Richard | last4 = Scofield | first4 = Robert Hal | last5 = Quadri | first5 = Syed M.S. | last6 = Murphy | first6 = Taylor A. | last7 = Liles | first7 = Campbell | last8 = Harris | first8 = Valerie M. | last9 = Koelsch | first9 = Kristi A. | date = 2017-07-01 | title = Antiadrenergic autoimmunity in postural tachycardia syndrome|url=https://academic.oup.com/europace/article/19/7/1211/2952372|journal=EP Europace|language=en|volume=19|issue=7|pages=1211–1219|doi=10.1093/europace/euw154|issn=1099-5129}}</ref>, muscarinic<ref>{{Cite journal | last = Yu | first = Xichun | last2 = Stavrakis | first2 = Stavros | last3 = Hill | first3 = Michael A. | last4 = Huang | first4 = Shijun | last5 = Reim | first5 = Sean | last6 = Li | first6 = Hongliang | last7 = Khan | first7 = Muneer | last8 = Hamlett | first8 = Sean | last9 = Cunningham | first9 = Madeleine W. | date = 2012-01-01 | title = Autoantibody activation of beta-adrenergic and muscarinic receptors contributes to an “autoimmune” orthostatic hypotension|url=http://www.sciencedirect.com/science/article/pii/S1933171111002452|journal=Journal of the American Society of Hypertension|volume=6|issue=1 | pages = 40–47|doi=10.1016/j.jash.2011.10.003|issn=1933-1711}}</ref> and other autoantibodies<ref>{{Cite journal | last = Thieben | first = Mark J. | last2 = Sandroni | first2 = Paola | last3 = Sletten | first3 = David M. | last4 = Benrud-Larson | first4 = Lisa M. | last5 = Fealey | first5 = Robert D. | last6 = Vernino | first6 = Steven | last7 = Low | first7 = Phillip A. | last8 = Lennon | first8 = Vanda A. | last9 = Shen | first9 = Win-Kuang | date = 2007-03-01 | title = Postural Orthostatic Tachycardia Syndrome: The Mayo Clinic Experience|url=http://www.sciencedirect.com/science/article/pii/S0025619611610276|journal=Mayo Clinic Proceedings|volume=82|issue=3|pages=308–313|doi=10.4065/82.3.308|issn=0025-6196}}</ref><ref>{{Cite journal | last = Li Hongliang | last2 = Yu Xichun | last3 = Liles Campbell | last4 = Khan Muneer | last5 = Vanderlinde‐Wood Megan | last6 = Galloway Allison | last7 = Zillner Caitlin | last8 = Benbrook Alexandria | last9 = Reim Sean | title = Autoimmune Basis for Postural Tachycardia Syndrome|url=https://www.ahajournals.org/doi/full/10.1161/JAHA.113.000755|journal=Journal of the American Heart Association|volume=3|issue=1| pages = e000755|doi=10.1161/JAHA.113.000755|pmc =  3959717|pmid=24572257}}</ref><ref>{{Cite journal | last = Lennon | first = Vanda | last2 = Low | first2 = Phillip | last3 = Klein | first3 = Christopher | last4 = Singer | first4 = Wolfgang | date = 2015-04-06 | title = Autoantibodies in the Postural Tachycardia Syndrome (P1.272)|url=https://n.neurology.org/content/84/14_Supplement/P1.272|journal=Neurology|language=en|volume=84|issue=14 Supplement|pages=P1.272|issn=0028-3878}}</ref> have been found. A small study of POTS in children found that 24.39% of patients had [[acetylcholine]] receptor autoantibodies.<ref>{{Cite journal | last = Li | first = Jiawei | last2 = Zhang | first2 = Qingyou | last3 = Liao | first3 = Ying | last4 = Zhang | first4 = Chunyu | last5 = Hao | first5 = Hongjun | last6 = Du | first6 = Junbao | date = 2014-08-03 | title = The Value of Acetylcholine Receptor Antibody in Children with Postural Tachycardia Syndrome|url=https://link.springer.com/article/10.1007/s00246-014-0981-8|journal=Pediatric Cardiology|language=en|volume=36|issue=1|pages=165–170|doi=10.1007/s00246-014-0981-8|issn=0172-0643}}</ref>A small study of adult patients found elevated α1, β1 and β2 adrenergic receptor autoantibodies.<ref>{{Cite journal | last = Li | first = Hongliang | last2 = Yu | first2 = Xichun | last3 = Liles | first3 = Campbell | last4 = Khan | first4 = Muneer | last5 = Vanderlinde‐Wood | first5 = Megan | last6 = Galloway | first6 = Allison | last7 = Zillner | first7 = Caitlin | last8 = Benbrook | first8 = Alexandria | last9 = Reim | first9 = Sean | date = 2014-01-27 | title = Autoimmune Basis for Postural Tachycardia Syndrome|url=https://www.ahajournals.org/doi/abs/10.1161/JAHA.113.000755|journal=Journal of the American Heart Association|language=EN|volume=3|issue=1|doi=10.1161/jaha.113.000755|issn=2047-9980|pmc=3959717|pmid=24572257}}</ref>


=Diagnosis=
Lax vasculature has been though to play a role in the development of POTS in people with Ehlers-Danlos Syndrome, a connective tissue disorder.<ref>{{Cite journal | last = Hakim | first = Alan | last2 = O'Callaghan | first2 = Chris | last3 = Wandele | first3 = Inge De | last4 = Stiles | first4 = Lauren | last5 = Pocinki | first5 = Alan | last6 = Rowe | first6 = Peter | date = 2017 | title=Cardiovascular autonomic dysfunction in Ehlers–Danlos syndrome—Hypermobile type|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/ajmg.c.31543|journal=American Journal of Medical Genetics Part C: Seminars in Medical Genetics|language=en|volume=175|issue=1|pages=168–174|doi=10.1002/ajmg.c.31543|issn=1552-4876}}</ref>


=Treatment=
==Testing==
A 2012 study [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/ Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review] concluded:
<embedvideo service="youtube" dimensions="400" alignment="right" container="frame" description="This interactive video explains what you can expect during the tilt table test. By eMedTV">https://www.youtube.com/watch?v=5H5FZTAic7c</embedvideo>
Assessing orthostatic blood pressure can be done in a physician's office by measuring the patient's blood pressure while lying down, sitting, and standing at standardized time increments. Dr. [[Lucinda Bateman]] uses a modified orthostatic blood pressure assessment called the [[NASA 10-minute lean test|NASA 10-minute Lean Test]], a variant of a test used by NASA researchers to test for orthostatic intolerance following space flight. The NASA 10-minute Lean Test is less taxing on the patient and can be done in any physician's office. Instructions are available for printout for both [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Test-Instructions-1.pdf healthcare providers] and [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Patient-Preparation-Instructions-1.pdf patients].<ref>{{Cite news | url=https://batemanhornecenter.org/assess-orthostatic-intolerance/ | title = Simple Way to Assess Orthostatic Intolerance - Bateman Horne Center | last=Bateman | first = Lucinda | date = 2016-09-27|work=Bateman Horne Center Newsletter|access-date=2018-08-16|archive-url=|archive-date=|url-status=|publisher=|language=en-US | authorlink = Lucinda Bateman}}</ref>


''Excerpt''
If the results of the standard orthostatic blood pressure assessment are inconclusive, a [[tilt table test]] can be used for diagnosis.<ref>{{Cite news | url=http://myheart.net/pots-syndrome/diagnosis-tests/ | title = How Doctors Diagnose & Test for POTS|work=MyHeart|access-date=2018-08-16|language=en-US}}</ref>


:The pathophysiology of POTS is complex and the result of a number of separate mechanisms producing a common pattern of symptoms. The large number of clinical manifesttations that characterize this disorder and the wide range of medications available, plus the clear evidence that certain medications and treatment strategies work in some, but not all POTS patients, demonstrates that POTS is a range of disorders requiring comprehensive investigation and characterisation to guide selection of the most appropriate treatment. The recent consensus statement will help to direct further research into the underlying conditions that lead to POTS.
==Treatment==
A 2012 study [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/ Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review]<ref name=":0" /> concluded:


:The following treatments were identified:
:"The pathophysiology of POTS is complex and the result of a number of separate mechanisms producing a common pattern of symptoms. The large number of clinical manifestations that characterize this disorder and the wide range of medications available, plus the clear evidence that certain medications and treatment strategies work in some, but not all POTS patients, demonstrates that POTS is a range of disorders requiring comprehensive investigation and characterisation to guide selection of the most appropriate treatment. The recent consensus statement will help to direct further research into the underlying conditions that lead to POTS."
:  When the cause of POTS is able to be identified and treated in certain individuals, their POTS symptoms may subside. However, there is currently no cure for POTS on the broader level. The following treatments have been identified to improve symptoms and quality of life:
:* Increasing fluid intake (2-3 liters a day)
:* Increasing salt intake
:* Raising the head of the bed to conserve blood volume (less blood is turned into urine by the kidneys when reclining at an angle)
:* Abdominal compression garments<ref>{{Cite journal|title=Abdominal Compression as a Treatment for Postural Tachycardia Syndrome|date=2020-07-21|url=https://www.ahajournals.org/doi/10.1161/JAHA.120.017610|journal=Journal of the American Heart Association|volume=9|issue=14|pages=e017610|last=Miller|first=Amanda J.|last2=Bourne|first2=Kate M.|language=en|doi=10.1161/JAHA.120.017610|pmc=PMC7660708|pmid=32673524|issn=2047-9980}}</ref>
:* [[Diet]]
:* Reclined exercise, such as rowing, biking, swimming (contraindicated in patients with co-morbid [[myalgic encephalomyelitis]])
:* [[saline|Sodium chloride]] 0.9% (Normal saline)
:* Medications:
:** [[:Category:Beta-blockers|Beta-blockers]]
:** [[Fludrocortisone]]
:** [[Ivabradine]]
:** [[Erythropoietin]]
:** [[Pyridostigmine|Pyridostigmine bromide]] (Mestinon)
:** [[:Category:Vasoconstrictors|Vasoconstrictors]]
:** [[Nonsteroidal anti-inflammatory drug|NSAIDs]]
:** Others such as [[methyldopa]] and [[antidepressant]]s<ref name=":1" /><ref name=":0">{{Cite journal | last = Abed | first=Howraa | last2 = Ball | first2 = Patrick A | last3 = Wang | first3 = Le-Xin | date = 2012  | title = Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/|journal=Journal of Geriatric Cardiology : JGC|volume=9|issue=1 | pages = 61–67|doi=10.3724/SP.J.1263.2012.00061|issn=1671-5411|pmid=22783324|via=}}</ref>
A small randomized crossover design trial found that patients with postural orthostatic tachychardia improved with Mestinon.<ref>{{Cite journal | last = Raj | first = S.R. | date = 2005-05-31 | title = Acetylcholinesterase Inhibition Improves Tachycardia in Postural Tachycardia Syndrome|url=https://www.ahajournals.org/doi/pdf/10.1161/circulationaha.104.497594|journal=Circulation|volume=111|issue=21|pages=2734–2740|doi=10.1161/circulationaha.104.497594|issn=0009-7322}}</ref>


:*Diet
==Conditions associated with POTS ==
:*Exercise
POTS is not only comorbid with a range of diseases, but its phenotype also resembles that of other disorders (e.g., ME, [[Ehlers-Danlos syndrome|Ehlers-Danlos Syndrome]]).
:*Sodium chloride 0.9% (Normal saline)
:*Beta-blockers
:*Fludrocortisone
:*Ivabradine
:*Erythropoietin
:*Pyridostigmine bromide
:*Vasoconstrictors
:*NSAIDs
:*Others such as methyldopa and antidepressants<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/ Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review - Journal of Geriatric Cardiology - NCBI]</ref>


==Things to avoid==
===ME/CFS ===
*Active constituents of [[medical marijuana]] cause a drop in blood pressure and other symptoms associated with [[postural hypotension]]. It is therefore recommended that POTS patients avoid marijuana. However, there are some positive anecdotal reports from patients regarding medical marijuana use.
POTS can be a co-morbid condition in [[ME/CFS]] patients.<ref>{{Cite web|url=https://www.youtube.com/watch?v=o4OqNPZoqVs | title = POTS in ME/CFS | last = | first = | date = Aug 2, 2014 | website = Freedom From ME - The Optimum Health Clinic on YouTube|publisher=|archive-url=|archive-date=|url-status=|access-date= | authorlink = }}</ref><ref>{{Cite web|url=https://ammes.org/overlapping-conditions/ | title = Overlapping Conditions – American ME and CFS Society|website=ammes.org|language=en-US|access-date=2018-08-12}}</ref> Estimates on the prevalence of POTS among [[ME/CFS]] patients varies widely, from 11% to 70%.  In a 2008 study done in the UK by the Northern CFS/ME Clinical Network, using the [[Fukuda criteria]], 27% of the study population had POTS compared with 9% in the control population.<ref name=":2">{{Cite journal | last = Hoad | first = A. | authorlink = | last2 = Spickett | first2 = G. | author-link2 = Gavin Spickett‎ | last3 = Elliott | first3 = J. | author-link3 = | last4 = Newton | first4 = J. | author-link4 = Julia Newton | date = 2008 | title  = Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome | url = https://www.ncbi.nlm.nih.gov/pubmed/18805903 | journal = QJM: monthly journal of the Association of Physicians | volume = 101 | issue = 12 | pages = 961–965 | doi = 10.1093/qjmed/hcn123 | issn=1460-2393 | pmid = 18805903 | quote = | via = }}</ref>


=Related conditions =
{| class="wikitable"
! colspan="3" |Prevalence of POTS in ME/CFS population samples
|-
!Study:
!number of
ME/CFS patients
!%
POTS
|-
|[[pubmed:10431117|Stewart et al. 1999]]
|25
|70%
|-
|[[pubmed:10189122|Schondorf et al. 1999]]
|75
|40%
|-
|[[pubmed:18805903|Hoad et al. 2008]]
|59
|27%
|-
|[https://www.frontiersin.org/articles/10.3389/fped.2018.00349/full Van Campen et al. 2018]
|627
|25%
|-
|Dowsett & Ramsay, 1990<ref>{{Cite journal | last = Dowsett | first=E. G. | last2 = Ramsay | first2 = A.M. | last3 = McCartney | first3 = R.A. | last4 = Bell | first4 = E.J. | date = Jul 1990 | title = Myalgic encephalomyelitis--a persistent enteroviral infection?|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429637/|journal=Postgraduate Medical Journal|volume=66|issue=777 | pages = 526–530|issn=0032-5473|pmc=2429637|pmid=2170962}}</ref>
|420
|21%
|-
|[[pubmed:23206180|Lewis et al. 2013]]
|179
|13%
|-
|[[pubmed:24206536|Reynolds et al. 2014]]
|306
|11%
|-
|[[pubmed:27696568|Roerink et al. 2017]]
|419
|5,7%
|}
A 2011 study of 58 POTS patients by the Vanderbilt Autonomic Dysfunction Center (Vanderbilt University School of Medicine, Nashville, TN, U.S.A.), reported that 64% of also met the [[Centers for Disease Control and Prevention]] (CDC) criteria for [[chronic fatigue syndrome]].<ref>{{Cite journal | last = Okamoto | first = Luis E. | last2 = Raj | first2 = Satish R. | last3 = Peltier | first3 = Amanda | last4 = Gamboa | first4 = Alfredo | last5 = Shibao | first5 = Cyndya | last6 = Diedrich | first6 = André | last7 = Black | first7 = Bonnie K. | last8 = Robertson | first8 = David | last9 = Biaggioni | first9 = Italo | date = 2012-02-01 | title = Neurohumoral and haemodynamic profile in postural tachycardia and chronic fatigue syndromes|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203411/|journal=Clinical Science (London, England : 1979)|volume=122|issue=Pt 4|pages=183–192|doi=10.1042/CS20110200|issn=0143-5221|pmid=21906029|via=}}</ref>


==ME/CFS ==
The [[SEID]] criteria requires either [[orthostatic intolerance]] (of which POTS is one type) or [[cognitive dysfunction]] for a diagnosis.<ref name="IOM2015">{{Cite book | last = Institute of Medicine | first = | date = 2015-03-16 | title = Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness.|url=https://www.nap.edu/read/19012/chapter/6#114|language=en|volume=|at=Box 4-3, p 114|doi=10.17226/19012|via=NAP.edu|issue=|quote= | author-link = Institute of Medicine|publisher=The National Academies Press|location=Washington, DC}}</ref> POTS is also a symptom of the [[Canadian Consensus Criteria]] (CCC) which diagnoses ME/CFS,<ref>{{Cite web|url=http://me-pedia.org/wiki/Canadian_Consensus_Criteria#Definition | title = Canadian Consensus Criteria - MEpedia|website=me-pedia.org|language=en|access-date=2018-08-16}}</ref> and the [[International Consensus Criteria]] (ICC) for diagnosing [[myalgic encephalomyelitis]] (ME).<ref>{{Cite web|url=http://me-pedia.org/wiki/International_Consensus_Criteria#D._Energy_production.2Ftransportation_impairments:_At_least_one_symptom | title = International Consensus Criteria - MEpedia|website=me-pedia.org|language=en|access-date=2018-08-16}}</ref> However, the diagnosis of POTS alone does not automatically support a [[ME/CFS]] diagnosis and cannot be used as a [[diagnostic biomarker]] to determine ME/CFS. POTS can occur independent from ME/CFS, and, likewise, ME/CFS can occur without the symptomatology of POTS.
POTS can be a co-morbid condition in [[ME/CFS]] patients.<ref>[https://www.youtube.com/watch?v=o4OqNPZoqVs POTS in ME/CFS - youtube]</ref> In a 2008 study done in the UK by the Northern CFS/ME Clinical Network, using the [[Fukuda criteria]], 27% of the study population had POTS compared with 9% in the control population.The researchers concluded:"POTS is a frequent finding in patients with CFS/ME. We suggest that clinical evaluation of patients with CFS/ME should include response to standing. Studies are needed to determine the optimum intervention strategy to manage POTS in those with CFS/ME."<ref>[Hoad A, Spickett G, Elliott J, Newton J. (2008). Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome. ''QJM,'' ''101''(12):961-5. doi: 10.1093/qjmed/hcn123. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18805903]</ref>


A 2011 study, by the Vanderbilt Autonomic Dysfunction Center (Vanderbilt University School of Medicine, Nashville, TN, U.S.A.), reported that 64% of the POTS population in the study also met the [[Centers for Disease Control & Prevention]] criteria for [[chronic fatigue syndrome]].<ref>Okamoto, L. E., Raj, S. R., Peltier, A., Gamboa, A., Shibao, C., Diedrich, A., . . . Biaggioni, I. (2011). Neurohumoral and haemodynamic profile in postural tachycardia and chronic fatigue syndromes. ''Clinical Science, 122''(4), 183-192. doi:10.1042/CS20110200 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203411/</ref>
A 2016 study in the Netherlands by Roerink et al., found that patients with CFS who fulfilled the [[SEID]] criteria did not have a prevalence of POTS different from that in the overall ME/CFS population. In adults with ME/CFS, the prevalence of POTS was low, between 6% - 18% (depending on age), was not different from the rate in non-ME/CFS fatigued patients, and was not related to disease severity or treatment outcome.<ref>{{Cite journal | last = Roerink | first = M. E. | last2 = Lenders | first2 = J. W.M. | last3 = Schmits | first3 = I.C. | last4 = Pistorius | first4 = A.M.A. | last5 = Smit | first5 = J.W. | last6 = Knoop | first6 = H. | last7 = van der Meer | first7 = J.W.M. | date = 2016-10-02 | title = Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome|url=https://doi.org/10.1111/joim.12564|journal=Journal of Internal Medicine|language=en|volume=281|issue=2|pages=179–188|doi=10.1111/joim.12564|issn=0954-6820|via= | authorlink7 = Jos van der Meer}}</ref>


The proposed [[SEID]] criteria has OI as a symptom but it is not necessary for a diagnosis as it is not always present. If the patient does not have OI they would have to have Cognitive Impairment ([[Cognitive dysfunction]]) to meet SEID criteria.
ME patients with POTS can experience impaired neurocognitive abilities (such as working memory, information processing) under increased orthostatic stress (i.e., standing, [[tilt table test]]).<ref>{{Cite journal | last = Ocon | first = Anthony J. | last2 = Messer | first2 = Zachary R. | last3 = Medow | first3 = Marvin S. | last4 = Stewart | first4 = Julian M. | date = Mar 2012 | title = Increasing orthostatic stress impairs neurocognitive functioning in chronic fatigue syndrome with postural tachycardia syndrome|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368269/|journal=Clinical Science (London, England : 1979)|volume=122|issue=5|pages=227–238|doi=10.1042/CS20110241|issn=0143-5221|pmc=3368269|pmid=21919887|quote= | authorlink3 = Marvin Medow | author-link4 = Julian Stewart | author-link5 = |via=}}</ref>


The diagnosis of POTS alone does not automatically support a [[ME/CFS]] diagnosis and can not be used as a [[diagnostic biomarker]] to determine ME/CFS. POTS can occur independent from ME/CFS, and, likewise, ME/CFS can occur without the symptomatology of POTS. A September 2016 study in the Netherlands by Roerink, et al, found that patients with CFS who fulfilled the [[SEID]] criteria did not have a prevalence of POTS different from that in the overall CFS population. In adults with CFS, the prevalence of POTS was low, between 6% - 18% (depending on age), was not different from the rate in non-CFS fatigued patients and was not related to disease severity or treatment outcome.<ref name="Roerink, 2016"/>
=== Other conditions associated with POTS ===
*[[Ehlers-Danlos syndrome|Ehlers Danlos syndrome]]<ref name=":3" />


==Ehlers Danlos Syndrome==
*[[Fibromyalgia]]<ref name=":30">{{Cite web|url=https://ammes.org/overlapping-conditions/ | title = Overlapping Conditions - American Myalgic Encephalomyelitis and Chronic Fatigue Syndrome Society | last = | first = | date = |website=ammes.org|language=en-US|archive-url=|archive-date=|url-status=|access-date=2018-08-12}}</ref><ref>{{Cite journal | last = Yun | first = Dong Joo | last2 = Choi | first2 = Han Na | last3 = Oh | first3 = Gun-Sei | date = 2013  | title = A Case of Postural Orthostatic Tachycardia Syndrome Associated with Migraine and Fibromyalgia|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710947/|journal=The Korean Journal of Pain|volume=26|issue=3|pages=303–306|doi=10.3344/kjp.2013.26.3.303|issn=2005-9159|pmid=23862007|via=}}</ref>
''{{main article|Ehlers-Danlos syndrome}}''


== Studies ==
*[[Autoimmune disease|Autoimmune diseases]]<ref name=":1" />
*2018, Managing fatigue in postural tachycardia syndrome (PoTS): The Newcastle approach<ref name="Strassheim, 2018"/> [https://www.ncbi.nlm.nih.gov/pubmed/29519643 (Abstract)]
 
*2016, Is Postural Orthostatic Tachycardia a Useful Diagnostic Marker in Chronic Fatigue Syndrome Patients?[http://www.jpsychores.com/article/S0022-3999%2816%2930280-X/abstract (Abstract)]
*[[Chiari malformation]]<ref>{{Cite journal | last = Weig | first = Spencer G. | last2 = Buckthal | first2 = Paul E. | last3 = Choi | first3 = Samuel K. | last4 = Zellem | first4 = Ronald T. | date = 1991-10-01 | title = Recurrent syncope as the presenting symptom of Arnold‐Chiari malformation|url=http://n.neurology.org/content/41/10/1673|journal=Neurology|language=en|volume=41|issue=10|pages=1673–1673|doi=10.1212/WNL.41.10.1673|issn=0028-3878|pmid=1922816}}</ref><ref>{{Cite journal | last = Prilipko | first = O. | last2 = Dehdashti | first2 =  A.R. | last3 = Zaim | first3 = S. | last4 = Seeck | first4 = M. | date = 2005-07-01 | title = Orthostatic intolerance and syncope associated with Chiari type I malformation|url=https://jnnp.bmj.com/content/76/7/1034|journal=Journal of Neurology, Neurosurgery & Psychiatry|language=en|volume=76|issue=7|pages=1034–1036|doi=10.1136/jnnp.2004.048330|issn=0022-3050|pmid=15965223}}</ref>
*2016, [http://onlinelibrary.wiley.com/doi/10.1111/joim.12564/full Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome]<ref name="Roerink, 2016"/>  
 
*2014, [http://hic.sagepub.com/content/2/1/2324709614527812.full Postural Orthostatic Tachycardia With Chronic Fatigue After HPV Vaccination as Part of the “Autoimmune/Auto-inflammatory Syndrome Induced by Adjuvants”]
*Infections such as [[mononucleosis]], [[Epstein-Barr virus|Epstein-Barr virus]], [[Lyme disease]], [[Mycoplasma pneumoniae|extra-pulmonary Mycoplasma pneumonia]], and [[Hepatitis C]] <ref>{{Cite journal | last = Kanjwal | first = Khalil | last2 = Karabin | first2 = Beverly | last3 = Kanjwal | first3 = Yousuf | last4 = Grubb | first4 = Blair P.| date = 2011  | title = Postural orthostatic tachycardia syndrome following Lyme disease|url=https://www.ncbi.nlm.nih.gov/pubmed/21305487|journal=Cardiology Journal|volume=18|issue=1 | pages = 63–66|issn=1897-5593|pmid=21305487}}</ref><ref>{{Cite journal | last = Kasmani | first = Rahil | last2 = Elkambergy | first2 = Hossam | last3 = Okoli | first3 = Kelechi | date = Sep 2009  | title = Postural Orthostatic Tachycardia Syndrome Associated With Mycoplasma pneumoniae|url=http://journals.lww.com/infectdis/Abstract/2009/09000/Postural_Orthostatic_Tachycardia_Syndrome.16.aspx|journal=Infectious Diseases in Clinical Practice|language=en-US|volume=17|issue=5|pages=342–343|doi=10.1097/IPC.0b013e318191781b|issn=1056-9103}}</ref>
*2014, [http://www.ncbi.nlm.nih.gov/pubmed/24206536 Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an Australian cohort]<ref name="Reynolds2014"/>
 
*2013, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896080/ What is brain fog? An evaluation of the symptom in postural tachycardia syndrome]<ref name="Ross, 2013"/>
*[[Mitochondrial disorder|Mitochondrial diseases]]<ref>{{Cite journal | last = Kanjwal | first = Khalil | last2 = Karabin | first2 = Beverly | last3 = Kanjwal | first3 = Yousuf | last4 = Saeed | first4 = Bilal | last5 = Grubb | first5 = Blair P. | date = Oct 2010 | title = Autonomic dysfunction presenting as orthostatic intolerance in patients suffering from mitochondrial cytopathy|url=https://www.ncbi.nlm.nih.gov/pubmed/20960537|journal=Clinical Cardiology|volume=33|issue=10 | pages = 626–629|doi=10.1002/clc.20805|issn=1932-8737|pmid=20960537}}</ref>
*2012, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/ Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review]
 
*2008, [http://www.ncbi.nlm.nih.gov/pubmed/18805903 Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome]<ref name="Hoad, 2008"/>
*[[Mast cell activation disorder|Mast cell activation disorders]]<ref>{{Cite journal | last = Raj | first = Satish R | date = 2006-04-01 | title = The Postural Tachycardia Syndrome (POTS): Pathophysiology, Diagnosis & Management|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1501099/|journal=Indian Pacing and Electrophysiology Journal|volume=6|issue=2 | pages = 84–99|issn=0972-6292|pmc=1501099|pmid=16943900}}</ref>
 
*[[Syncope|Vasovagal syncope]]<ref>{{Cite journal | last = Garland | first=Emily M | last2 = Celedonio | first2 = Jorge E | last3 = Raj | first3 = Satish R | date = Sep 2015 | title = Postural Tachycardia Syndrome: Beyond Orthostatic Intolerance|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664448/|journal=Current neurology and neuroscience reports|volume=15|issue=9 | pages = 60|doi=10.1007/s11910-015-0583-8|issn=1528-4042|pmc=4664448|pmid=26198889}}</ref>
 
== Notable research ==
*2008, Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome<ref name=":2" /> [https://academic.oup.com/qjmed/article/101/12/961/1564413 (Full Text)]
*2012, Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review<ref>{{Cite journal | last = Abed | first=Howraa | last2 = Ball | first2 = Patrick A | last3 = Wang | first3 = Le-Xin | date = 2012  | title = Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/|journal=Journal of Geriatric Cardiology : JGC|volume=9|issue=1 | pages = 61–67|doi=10.3724/SP.J.1263.2012.00061|issn=1671-5411|pmid=22783324|via=}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390096/ (Full Text)]
*2012, Increasing orthostatic stress impairs neurocognitive abilities in chronic fatigue syndrome with postural tachycardia syndrome<ref>{{Cite journal | last = Ocon | first = Anthony J. | author-link = | last2 = Messer | first2 = Zachary R. | authorlink2 = | last3 = Medow | first3 = Marvin S. | authorlink3 = Marvin Medow | last4 = Stewart | author-link4 = Julian Stewart | author-link5 = | date = 2012  | title = Increasing orthostatic stress impairs neurocognitive functioning in chronic fatigue syndrome with postural tachycardia syndrome|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368269/|journal=Clinical Science (London, England : 1979)|volume=122|issue=5|pages=227–238|doi=10.1042/CS20110241|issn=0143-5221|pmc=3368269|pmid=21919887|quote=|via= | first4 = Julian M.}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368269/ (Full Text)]
*2013, What is [[brain fog]]? An evaluation of the symptom in postural tachycardia syndrome<ref>{{Cite journal | last = Ross | first=Amanda J. | last2 = Medow | first2 = Marvin S. | authorlink2 = Marvin Medow | last3 = Rowe | first3 = Peter C. | authorlink3 = Peter Rowe | last4 = Stewart | first4 = Julian M. | authorlink4 = Julian Stewart | date = 2013-09-03 | title = What is brain fog? An evaluation of the symptom in postural tachycardia syndrome|url=https://link.springer.com/article/10.1007%2Fs10286-013-0212-z|journal=Clinical Autonomic Research|language=en|volume=23|issue=6|pages=305–311|doi=10.1007/s10286-013-0212-z|issn=0959-9851|pmc=|pmid=23999934|via=}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896080/ (Full Text)]
*2014, Postural Orthostatic Tachycardia With Chronic Fatigue After [[HPV vaccine|HPV Vaccination]] as Part of the “[[Autoimmune syndrome induced by adjuvants|Autoimmune/Auto-inflammatory Syndrome Induced by Adjuvants]]”<ref>{{Cite journal | last = Tomljenovic | first = Lucija | last2 = Colafrancesco | first2 = Serena | last3 = Perricone | first3 = Carlo | last4 = Shoenfeld | first4 = Yehuda | date = 2014-03-13 | title = Postural Orthostatic Tachycardia With Chronic Fatigue After HPV Vaccination as Part of the “Autoimmune/Auto-inflammatory Syndrome Induced by Adjuvants”|url=http://journals.sagepub.com/doi/full/10.1177/2324709614527812|journal=Journal of Investigative Medicine High Impact Case Reports|language=en|volume=2|issue=1|pages=|doi=10.1177/2324709614527812|issn=2324-7096|pmid=26425598|via=|quote=}}</ref> [https://journals.sagepub.com/doi/full/10.1177/2324709614527812 (Full Text)]
*2014, Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an [[Australia|Australian]] cohort<ref name="Reynolds2014">{{Cite journal | last = Reynolds | first=G. K. | last2 = Lewis | first2 =  D.P. | last3 = Richardson | first3 = A.M. | last4 = Lidbury | first4 = B.A. | date = 2013-11-29 | title = Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an Australian cohort|url=https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12161|journal=Journal of Internal Medicine|language=en|volume=275|issue=4 | pages = 409–417|doi=10.1111/joim.12161|issn=0954-6820 | authorlink =  | author-link2 = Donald Lewis | authorlink3 =  | authorlink4 = Brett Lidbury | authorlink5 = |via=}}</ref> [https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12161 (Full Text)]
*2015, An assessment of fatigue in patients with postural orthostatic tachycardia syndrome<ref name="Wise2015">{{Cite journal | last = Wise | first = Shelby | last2 = Ross | first2 = Amanda | last3 = Brown | first3 = Abigail | authorlink3 = Abigail Brown | last4 = Evans | first4 = Meredyth  | authorlink4 = Meredyth Evans | last5 = Jason | first5 = Leonard | authorlink5 = Leonard Jason | date = 2015-11-04 | title = An assessment of fatigue in patients with postural orthostatic tachycardia syndrome|url=https://journals.sagepub.com/action/captchaChallenge?redirectUri=%2Fdoi%2F10.1177%2F1359105315613624|journal=Journal of Health Psychology|language=en|volume=22|issue=6 | pages = 733–742|doi=10.1177/1359105315613624|issn=1359-1053|via=}}</ref> ''(reprinted in 2017)'' [[pubmed:26537521|(Abstract)]]
*2016, Is Postural Orthostatic Tachycardia a Useful [[Diagnostic biomarker|Diagnostic Marker]] in Chronic Fatigue Syndrome Patients?<ref name="Roerink2016">{{Cite journal | last = Roerink | first = M.E. | last2 = Lenders | first2 = J.W.M | last3 = Schmits | first3 = I.C. | last4 = Pistorius | first4 = A. | last5 = Knoop | first5 = H. | last6 = van der Meer | first6 = J.W.M. | date = 2016 | title=Is Postural Orthostatic Tachycardia a Useful Diagnostic Marker in Chronic Fatigue Syndrome Patients?|url=http://www.jpsychores.com/article/S0022-3999(16)30280-X/abstract|journal=Journal of Psychosomatic Research|language=English|volume=85 | pages = 78|doi=10.1016/j.jpsychores.2016.03.193|issn=0022-3999|via= | authorlink6 = Jos van der Meer}}</ref> [http://www.jpsychores.com/article/S0022-3999%2816%2930280-X/abstract (Abstract)]
*2016, Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome<ref name="Roerink2016b">{{Cite journal | last = Roerink | first = M. E. | last2 = Lenders | first2 = J. W.M. | last3 = Schmits | first3 = I.C. | last4 = Pistorius | first4 = A.M.A. | last5 = Smit | first5 = J.W. | last6 = Knoop | first6 = H. | last7 = van der Meer | first7 = J.W.M. | date = 2016-10-02 | title = Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome|url=https://doi.org/10.1111/joim.12564|journal=Journal of Internal Medicine|language=en|volume=281|issue=2|pages=179–188|doi=10.1111/joim.12564|issn=0954-6820|via= | authorlink7 = Jos van der Meer}}</ref> [https://onlinelibrary.wiley.com/doi/abs/10.1111/joim.12564 (Abstract)]  
*2018, Managing fatigue in postural tachycardia syndrome (PoTS): The Newcastle approach<ref name="Strassheim2018">{{Cite journal | last = Strassheim | first = Victoria | authorlink = Victoria Strassheim | last2 = Welford | first2 = Jenny | authorlink2 = | last3 = Ballantine | first3 = Rob | authorlink3 = | last4 = Newton | first4 = Julia L. | authorlink4 = Julia Newton | authorlink5 =  | date = Dec 2018 | title = Managing fatigue in postural tachycardia syndrome (PoTS): The Newcastle approach|url=https://linkinghub.elsevier.com/retrieve/pii/S1566070217303284|journal=Autonomic Neuroscience|language=en|volume=215|issue= | pages = 56–61|doi=10.1016/j.autneu.2018.02.003|quote=|via=}}</ref> [https://www.ncbi.nlm.nih.gov/pubmed/29519643 (Abstract)]
*2018, Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management<ref name="Zadourian2018">{{Cite journal | last = Zadourian | first = Adena | last2 = Doherty | first2 = Taylor A. | last3 = Swiatkiewicz | first3 = Iwona | last4 = Taub | first4 = Pam R. | date = 2018-06-15 | title = Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management|url=https://link.springer.com/article/10.1007/s40265-018-0931-5|journal=Drugs|language=en|volume=78|issue=10 | pages = 983–994|doi=10.1007/s40265-018-0931-5|issn=0012-6667}}</ref> [https://link.springer.com/article/10.1007%2Fs40265-018-0931-5 (Abstract)]
*2019, [https://www.ahajournals.org/doi/full/10.1161/JAHA.119.013602 Postural Orthostatic Tachycardia Syndrome Is Associated With Elevated G‐Protein Coupled Receptor Autoantibodies]<ref name=":4" /> [https://www.ahajournals.org/doi/full/10.1161/JAHA.119.013602 (Full text)]


==Learn more==
==Learn more==
*[http://www.potsuk.org/ POTS UK website]
*[http://www.potsuk.org/ POTS UK website]
*[https://www.youtube.com/watch?v=5iF30TVLaRE September 2010, "Mangaging Orthostatic Intolerance"], by Dr [[Peter Rowe]]
*Sep 2010, [https://www.youtube.com/watch?v=5iF30TVLaRE Mangaging Orthostatic Intolerance]<ref>{{Cite web|url=https://www.youtube.com/watch?v=5iF30TVLaRE | title = Managing Orthostatic Intolerance | last = | first = | date = Sep 1, 2010 | website = SolveCFS on YouTube|publisher=|archive-url=|archive-date=|url-status=|access-date=}}</ref>
*[https://www.ncbi.nlm.nih.gov/pubmed/26967958 Recognizing postural orthostatic tachycardia syndrome]
*2016, [https://www.ncbi.nlm.nih.gov/pubmed/26967958 Recognizing postural orthostatic tachycardia syndrome]<ref>{{Cite journal | last = Pavlik | first = Daniel | last2 = Agnew | first2 = Donna | last3 = Stiles | first3 = Lauren | last4 = Ditoro | first4 = Rachel | date = 2016 | title=Recognizing postural orthostatic tachycardia syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/26967958|journal=JAAPA: official journal of the American Academy of Physician Assistants|volume=29|issue=4|pages=17–23|doi=10.1097/01.JAA.0000481398.76099.09|issn=1547-1896|pmid=26967958|via=}}</ref>
*2016, [http://www.healthrising.org/blog/2016/07/04/exercise-intolerance-fibromyalgia-chronic-fatigue-pots-explained/ The Exercise Intolerance in POTS, ME/CFS and Fibromyalgia Explained?]
*2016, [http://www.healthrising.org/blog/2016/07/04/exercise-intolerance-fibromyalgia-chronic-fatigue-pots-explained/ The Exercise Intolerance in POTS, ME/CFS and Fibromyalgia Explained?]<ref>{{Cite news | url=http://www.healthrising.org/blog/2016/07/04/exercise-intolerance-fibromyalgia-chronic-fatigue-pots-explained/ | title = The Exercise Intolerance in POTS, ME/CFS and Fibromyalgia Explained? - Health Rising | last = Johnson | first =Cort | date = 2016-07-04|work=Health Rising|access-date=2018-08-16|archive-url=|archive-date=|url-status=|language=en-US | authorlink = Cort Johnson}}</ref>
*2019, [http://news.utoledo.edu/index.php/09_10_2019/study-may-unlock-new-diagnostic-tools-for-fainting-disorder&#x20;http://news.utoledo.edu/index.php/09_10_2019/study-may-unlock-new-diagnostic-tools-for-fainting-disorder Study may unlock new diagnostic tools for fainting disorder] - possible biomarker for POTS and autoimmune evidence - University of Toledo


==See also==
==See also==
*[[Tilt table test]]
*[[Tilt table test]]
*[[Dysautonomia]]


== References ==
== References ==
<references>
{{reflist}}
<ref name="Hoad, 2008">
{{Citation
| last1  = Hoad                | first1 = A.                | authorlink1 =
| last2  = Spickett            | first2 = Gavin              | authorlink2 =
| last3  = Elliott              | first3 = J.                | authorlink3 =
| last4  = Newton              | first4 = Julia              | authorlink4 = Julia Newton
| title  = Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome.
| journal = QJM: monthly journal of the Association of Physicians    | volume = 101  | issue = 12  | page = 961-5
| date    = 2008
| pmid    = 18805903
| doi    = 10.1093/qjmed/hcn123
}}
</ref>
<ref name="Reynolds2014">{{citation
| last1  = Reynolds        | first1 = GK                | authorlink1 =
| last2  = Lewis            | first2 = Donald P          | authorlink2 = Donald Lewis
| last3  = Richardson      | first3 = AM                | authorlink3 =
| last4  = Lidbury          | first4 = Brett A            | authorlink4 = Brett Lidbury
| display-authors =
| title  = Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an Australian cohort
| journal = Journal of Internal Medicine | volume = Volume 275, Issue 4 | pages = 409–417
| date    = April 2014
| pmid    = 24206536 | doi = 10.1111/joim.12161
| url    = http://onlinelibrary.wiley.com/doi/10.1111/joim.12161/abstract
}}</ref>
<ref name="Roerink, 2016">
{{Citation
| last1  = Roerink            | first1 = M. E.            | authorlink1 =
| last2  = Lenders            | first2 = J. W.            | authorlink2 =
| last3  = Schmits            | first3 = I. C.            | authorlink3 =
| last4  = Pistorius          | first4 = A. M.            | authorlink4 =
| last5  = Smit                | first5 = J. W.            | authorlink5 =
| last6  = Knoop              | first6 = H.                | authorlink6 =
| last7  = van der Meer        | first7 = J. W. M.          | authorlink7 = Jos van der Meer
| title  = Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome
| journal = Journal of Internal Medicine    | volume =    | issue =    | page =
| date    = 2016
| pmid    = 27696568
| doi    = 10.1111/joim.12564
}}
</ref>
<ref name="Ross, 2013">
{{Citation
| last1  = Ross                  | first1 = A. J.                  | authorlink1 =
| last2  = Medow                | first2 = M. S.                  | authorlink2 = Marvin Medow
| last3  = Rowe                  | first3 = P. C.                  | authorlink3 = Peter Rowe
| last4  = Stewart              | first4 = J. M.                  | authorlink4 =
| title  = What is brain fog? An evaluation of the symptom in postural tachycardia syndrome.
| journal = Clinical Autonomic Research : Official Journal of the Clinical Autonomic Research Society  | volume = 23 | issue = 6  | page = 305–311
| date    = 2013
| doi    = 10.1007/s10286-013-0212-z
}}
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<ref name="Strassheim, 2018">
{{Citation
| last1  = Strassheim            | first1 = V              | authorlink1 =
| last2  = Welford              | first2 = J              | authorlink2 =
| last3  = Ballantine            | first3 = R              | authorlink3 =
| last4  = Newton                | first4 = JL            | authorlink4 = Julia Newton
| title  = Managing fatigue in postural tachycardia syndrome (PoTS): The Newcastle approach.
| journal = Autonomic Neuroscience    | volume =    | issue =    | page =
| date    = 2018
| pmid    =
| doi    = 10.1016/j.autneu.2018.02.003
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</ref>


</references>
[[Category:Diagnoses]]  
[[Category:Diagnoses]] [[Category:Comorbidities]] [[Category:Signs and symptoms]]
[[Category:Potential comorbidities]]  
[[Category:Signs and symptoms]]
[[Category:Cardiac signs and symptoms]]
[[Category:Cardiac signs and symptoms]]
[[Category:Neurological signs and symptoms]]
[[Category:Autonomic nervous system disorders]]
[[Category:Energy production or transportation symptoms]]
[[Category:Cardiovascular diseases and disorders]]

Latest revision as of 05:40, August 16, 2023

Postural orthostatic tachycardia syndrome (POTS, or postural tachycardia syndrome) is a condition in which a change from the supine position (lying horizontally) to an upright position causes an abnormally large increase in heart rate, called tachycardia. It is a form of orthostatic intolerance (OI), a type of dysautonomia, which means a dysregulation of the autonomic nervous system (ANS). The autonomic nervous system controls those functions of the body that are considered automatic and involuntary, such as heart rate, blood pressure, respiration, digestion, and arousal. Other symptoms of an orthostatic nature — occurring in response to upright posture — typically accompany the tachycardia.[1] These include, but are not limited to headaches, fatigue, sweating, nausea; fainting and dizziness. The female to male ratio of patients with POTS is 4:1.[2][3]

Onset[edit | edit source]

Onset may be linked to infection including viruses like EBV or enteroviruses, trauma, surgery or stress.[4][5]

Signs and symptoms[edit | edit source]

Acrocyanosis in POTS. These images shows the legs of two patients with POTS, immediately after standing up and after standing for several minutes. The reddish-purple discoloration in the legs is very notable, due to poor circulation in the extremities, which returns to normal upon returning to a reclined position.Source: Abou-Diab, J., Moubayed, D., Taddeo, D., Jamoulle, O., & Stheneur, C. (2018). Acrocyanosis Presentation in Postural Orthostatic Tachycardia Syndrome. International Journal Of Clinical Pediatrics, 7(1-2), 13-16. License: CC-BY-NC 4.0

The main symptom of POTS is an abnormal increase in heart rate upon standing. The specific diagnostic criteria for POTS is an increase in heart rate from the lying to upright position of greater than 30 beats per minute, or a heart rate of greater than 120 beats per minute within 10 minutes of standing. There needs to be an absence of significant orthostatic hypotension (magnitude of blood pressure drop ≥ 20/10 mm Hg) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8920526/. Patients with POTS usually present with other symptoms, commonly occurring in the upright position. These include:

Common stimuli in daily life, such as modest exertion, food ingestion and heat, can exacerbate symptoms.[9]

Potential mechanisms[edit | edit source]

Autoimmunity is thought to play a role in many cases of POTS: adrenergic[10], muscarinic[11] and other autoantibodies[12][13][14] have been found. A small study of POTS in children found that 24.39% of patients had acetylcholine receptor autoantibodies.[15]A small study of adult patients found elevated α1, β1 and β2 adrenergic receptor autoantibodies.[16]

Lax vasculature has been though to play a role in the development of POTS in people with Ehlers-Danlos Syndrome, a connective tissue disorder.[17]

Testing[edit | edit source]

This interactive video explains what you can expect during the tilt table test. By eMedTV

Assessing orthostatic blood pressure can be done in a physician's office by measuring the patient's blood pressure while lying down, sitting, and standing at standardized time increments. Dr. Lucinda Bateman uses a modified orthostatic blood pressure assessment called the NASA 10-minute Lean Test, a variant of a test used by NASA researchers to test for orthostatic intolerance following space flight. The NASA 10-minute Lean Test is less taxing on the patient and can be done in any physician's office. Instructions are available for printout for both healthcare providers and patients.[18]

If the results of the standard orthostatic blood pressure assessment are inconclusive, a tilt table test can be used for diagnosis.[19]

Treatment[edit | edit source]

A 2012 study Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review[20] concluded:

"The pathophysiology of POTS is complex and the result of a number of separate mechanisms producing a common pattern of symptoms. The large number of clinical manifestations that characterize this disorder and the wide range of medications available, plus the clear evidence that certain medications and treatment strategies work in some, but not all POTS patients, demonstrates that POTS is a range of disorders requiring comprehensive investigation and characterisation to guide selection of the most appropriate treatment. The recent consensus statement will help to direct further research into the underlying conditions that lead to POTS."
When the cause of POTS is able to be identified and treated in certain individuals, their POTS symptoms may subside. However, there is currently no cure for POTS on the broader level. The following treatments have been identified to improve symptoms and quality of life:

A small randomized crossover design trial found that patients with postural orthostatic tachychardia improved with Mestinon.[22]

Conditions associated with POTS[edit | edit source]

POTS is not only comorbid with a range of diseases, but its phenotype also resembles that of other disorders (e.g., ME, Ehlers-Danlos Syndrome).

ME/CFS[edit | edit source]

POTS can be a co-morbid condition in ME/CFS patients.[23][24] Estimates on the prevalence of POTS among ME/CFS patients varies widely, from 11% to 70%. In a 2008 study done in the UK by the Northern CFS/ME Clinical Network, using the Fukuda criteria, 27% of the study population had POTS compared with 9% in the control population.[25]

Prevalence of POTS in ME/CFS population samples
Study: number of

ME/CFS patients

%

POTS

Stewart et al. 1999 25 70%
Schondorf et al. 1999 75 40%
Hoad et al. 2008 59 27%
Van Campen et al. 2018 627 25%
Dowsett & Ramsay, 1990[26] 420 21%
Lewis et al. 2013 179 13%
Reynolds et al. 2014 306 11%
Roerink et al. 2017 419 5,7%

A 2011 study of 58 POTS patients by the Vanderbilt Autonomic Dysfunction Center (Vanderbilt University School of Medicine, Nashville, TN, U.S.A.), reported that 64% of also met the Centers for Disease Control and Prevention (CDC) criteria for chronic fatigue syndrome.[27]

The SEID criteria requires either orthostatic intolerance (of which POTS is one type) or cognitive dysfunction for a diagnosis.[28] POTS is also a symptom of the Canadian Consensus Criteria (CCC) which diagnoses ME/CFS,[29] and the International Consensus Criteria (ICC) for diagnosing myalgic encephalomyelitis (ME).[30] However, the diagnosis of POTS alone does not automatically support a ME/CFS diagnosis and cannot be used as a diagnostic biomarker to determine ME/CFS. POTS can occur independent from ME/CFS, and, likewise, ME/CFS can occur without the symptomatology of POTS.

A 2016 study in the Netherlands by Roerink et al., found that patients with CFS who fulfilled the SEID criteria did not have a prevalence of POTS different from that in the overall ME/CFS population. In adults with ME/CFS, the prevalence of POTS was low, between 6% - 18% (depending on age), was not different from the rate in non-ME/CFS fatigued patients, and was not related to disease severity or treatment outcome.[31]

ME patients with POTS can experience impaired neurocognitive abilities (such as working memory, information processing) under increased orthostatic stress (i.e., standing, tilt table test).[32]

Other conditions associated with POTS[edit | edit source]

Notable research[edit | edit source]

Learn more[edit | edit source]

See also[edit | edit source]

References[edit | edit source]

  1. Mar, Philip L.; Raj, Satish R. (2014). "Neuronal and hormonal perturbations in postural tachycardia syndrome". Frontiers in Physiology. 5: 220. doi:10.3389/fphys.2014.00220. ISSN 1664-042X. PMID 24982638.
  2. "PoTS - Postural Tachycardia Syndrome". PoTS UK. Retrieved August 16, 2018.
  3. "PoTS - Postural Tachycardia Syndrome - What is POTS?". PoTS UK. Retrieved August 16, 2018.
  4. Grahame, Rodney; Kirbis, Mojca; Andrew P. Owens; Iodice, Valeria; Low, David A.; Mathias, Christopher J. (January 2012). "Postural tachycardia syndrome—current experience and concepts". Nature Reviews Neurology. 8 (1): 22–34. doi:10.1038/nrneurol.2011.187. ISSN 1759-4766.
  5. 5.0 5.1 5.2 Gunning, William T.; Kvale, Heather; Kramer, Paula M.; Karabin, Beverly L.; Grubb, Blair P. (September 17, 2019). "Postural Orthostatic Tachycardia Syndrome Is Associated With Elevated G‐Protein Coupled Receptor Autoantibodies". Journal of the American Heart Association. 8 (18): e013602. doi:10.1161/JAHA.119.013602.
  6. "Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)". Standing Up to POTS. July 9, 2018.
  7. Raj, Satish R (April 1, 2006). "The Postural Tachycardia Syndrome (POTS): Pathophysiology, Diagnosis & Management". Indian Pacing and Electrophysiology Journal. 6 (2): 84–99. ISSN 0972-6292. PMC 1501099. PMID 16943900.
  8. 8.0 8.1 8.2 "Dysautonomia International: Postural Orthostatic Tachycardia Syndrome". dysautonomiainternational.org. Retrieved October 25, 2018.
  9. 9.0 9.1 Grahame, Rodney; Kirbis, Mojca; Andrew P. Owens; Iodice, Valeria; Low, David A.; Mathias, Christopher J. (January 2012). "Postural tachycardia syndrome—current experience and concepts". Nature Reviews Neurology. 8 (1): 22–34. doi:10.1038/nrneurol.2011.187. ISSN 1759-4766.
  10. Kem, David C.; Melander, Olle; Sutton, Richard; Scofield, Robert Hal; Quadri, Syed M.S.; Murphy, Taylor A.; Liles, Campbell; Harris, Valerie M.; Koelsch, Kristi A. (July 1, 2017). "Antiadrenergic autoimmunity in postural tachycardia syndrome". EP Europace. 19 (7): 1211–1219. doi:10.1093/europace/euw154. ISSN 1099-5129.
  11. Yu, Xichun; Stavrakis, Stavros; Hill, Michael A.; Huang, Shijun; Reim, Sean; Li, Hongliang; Khan, Muneer; Hamlett, Sean; Cunningham, Madeleine W. (January 1, 2012). "Autoantibody activation of beta-adrenergic and muscarinic receptors contributes to an "autoimmune" orthostatic hypotension". Journal of the American Society of Hypertension. 6 (1): 40–47. doi:10.1016/j.jash.2011.10.003. ISSN 1933-1711.
  12. Thieben, Mark J.; Sandroni, Paola; Sletten, David M.; Benrud-Larson, Lisa M.; Fealey, Robert D.; Vernino, Steven; Low, Phillip A.; Lennon, Vanda A.; Shen, Win-Kuang (March 1, 2007). "Postural Orthostatic Tachycardia Syndrome: The Mayo Clinic Experience". Mayo Clinic Proceedings. 82 (3): 308–313. doi:10.4065/82.3.308. ISSN 0025-6196.
  13. Li Hongliang; Yu Xichun; Liles Campbell; Khan Muneer; Vanderlinde‐Wood Megan; Galloway Allison; Zillner Caitlin; Benbrook Alexandria; Reim Sean. "Autoimmune Basis for Postural Tachycardia Syndrome". Journal of the American Heart Association. 3 (1): e000755. doi:10.1161/JAHA.113.000755. PMC 3959717. PMID 24572257.
  14. Lennon, Vanda; Low, Phillip; Klein, Christopher; Singer, Wolfgang (April 6, 2015). "Autoantibodies in the Postural Tachycardia Syndrome (P1.272)". Neurology. 84 (14 Supplement): P1.272. ISSN 0028-3878.
  15. Li, Jiawei; Zhang, Qingyou; Liao, Ying; Zhang, Chunyu; Hao, Hongjun; Du, Junbao (August 3, 2014). "The Value of Acetylcholine Receptor Antibody in Children with Postural Tachycardia Syndrome". Pediatric Cardiology. 36 (1): 165–170. doi:10.1007/s00246-014-0981-8. ISSN 0172-0643.
  16. Li, Hongliang; Yu, Xichun; Liles, Campbell; Khan, Muneer; Vanderlinde‐Wood, Megan; Galloway, Allison; Zillner, Caitlin; Benbrook, Alexandria; Reim, Sean (January 27, 2014). "Autoimmune Basis for Postural Tachycardia Syndrome". Journal of the American Heart Association. 3 (1). doi:10.1161/jaha.113.000755. ISSN 2047-9980. PMC 3959717. PMID 24572257.
  17. Hakim, Alan; O'Callaghan, Chris; Wandele, Inge De; Stiles, Lauren; Pocinki, Alan; Rowe, Peter (2017). "Cardiovascular autonomic dysfunction in Ehlers–Danlos syndrome—Hypermobile type". American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 175 (1): 168–174. doi:10.1002/ajmg.c.31543. ISSN 1552-4876.
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  21. Miller, Amanda J.; Bourne, Kate M. (July 21, 2020). "Abdominal Compression as a Treatment for Postural Tachycardia Syndrome". Journal of the American Heart Association. 9 (14): e017610. doi:10.1161/JAHA.120.017610. ISSN 2047-9980. PMC 7660708. PMID 32673524.
  22. Raj, S.R. (May 31, 2005). "Acetylcholinesterase Inhibition Improves Tachycardia in Postural Tachycardia Syndrome". Circulation. 111 (21): 2734–2740. doi:10.1161/circulationaha.104.497594. ISSN 0009-7322.
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  30. "International Consensus Criteria - MEpedia". me-pedia.org. Retrieved August 16, 2018.
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