Postural orthostatic tachycardia syndrome

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. 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. The autonomic nervous system is in charge of heart rate and blood pressure but it has become disregulated.

Signs and symptoms

The following symptoms are common in POTS:

• Dizziness/ lightheadedness
• Headaches and migraines
• Cognitive impairment / brain fog
• Sleep abnormalities
• Neuropathic pain
• Fatigue
• Blood pooling in the extremities
• Sensory sensitivity
• Abdominal pain, gastroparesis, or rapid gastric emptying

Testing

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.

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

Treatment

A 2012 study Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review 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."

The following treatments were identified:

• Diet
• Exercise (contraindicated in patients with co-morbid myalgic encephalomyelitis)
• Sodium chloride 0.9% (Normal saline)
• Beta-blockers
• Fludrocortisone
• Ivabradine
• Erythropoietin
• Pyridostigmine bromide
• Vasoconstrictors
• NSAIDs
• Others such as methyldopa and antidepressants

Related conditions

ME/CFS

POTS can be a co-morbid condition in ME/CFS patients. Estimates on the prevalence of POTS among ME/CFS patients varies widely. 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.

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.

The proposed SEID criteria requires that either orthostatic intolerance (of which POTS is one type) or cognitive dysfunction for a diagnosis. 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 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.

Ehlers Danlos Syndrome

Main article: Ehlers-Danlos syndrome

Symptom recognition

POTS is a well documented symptom in Systemic Exertion Intolerance Disease (SEID), the Canadian Consensus Criteria (CCC) which diagnoses ME/CFS, and the International Consensus Criteria (ICC) for diagnosing Myalgic encephalomyelitis.

Studies

• 2008, Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome
• 2012, Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review
• 2013, What is brain fog? An evaluation of the symptom in postural tachycardia syndrome
• 2014, Postural Orthostatic Tachycardia With Chronic Fatigue After HPV Vaccination as Part of the “Autoimmune/Auto-inflammatory Syndrome Induced by Adjuvants”
• 2014, Comorbidity of postural orthostatic tachycardia syndrome and chronic fatigue syndrome in an Australian cohort
• 2016, Is Postural Orthostatic Tachycardia a Useful Diagnostic Marker in Chronic Fatigue Syndrome Patients?(Abstract)
• 2016, Postural orthostatic tachycardia is not a useful diagnostic marker for chronic fatigue syndrome
• 2018, Managing fatigue in postural tachycardia syndrome (PoTS): The Newcastle approach (Abstract)

Learn more

• POTS UK website
• Sep 2010, Mangaging Orthostatic Intolerance
• 2016, Recognizing postural orthostatic tachycardia syndrome
• 2016, The Exercise Intolerance in POTS, ME/CFS and Fibromyalgia Explained?

See also

• Tilt table test

postural orthostatic tachycardia syndrome (POTS) - A form of orthostatic intolerance where the cardinal symptom is excessive tachycardia due to changing position (e.g. from lying down to sitting up).

postural orthostatic tachycardia syndrome (POTS) - A form of orthostatic intolerance where the cardinal symptom is excessive tachycardia due to changing position (e.g. from lying down to sitting up).

tachycardia An unusually rapid heart beat. Can be caused by exercise or illness. A symptom of postural orthostatic tachycardia syndrome (POTS). (Learn more: www.heart.org)

supine lying on the back or with the face upward

orthostatic intolerance (OI) - The development of symptoms when standing upright, where symptoms are relieved upon reclining. Patients with orthostatic intolerance have trouble remaining upright for more than a few seconds or a few minutes, depending upon severity. In severe orthostatic intolerance, patients may not be able to sit upright in bed. Orthostatic intolerance is often a sign of dysautonomia. There are different types of orthostatic intolerance, including postural orthostatic tachycardia syndrome (POTS).

heart rate (HR) - the number of times the heart beats within a certain time period, usually a minute

systemic exertion intolerance disease (SEID) - A term for ME/CFS that aims to avoid the stigma associated with the term "chronic fatigue syndrome", while emphasizing the defining characteristic of post-exertional malaise (PEM). SEID was defined as part of the diagnostic criteria put together by the Institute of Medicine (IOM) report of 10 February 2015.

Canadian Consensus Criteria (CCC) - A set of diagnostic criteria used to diagnose ME/CFS, developed by a group of practicing ME/CFS clinicians in 2003. The CCC is often considered to be the most complex criteria, but possibly the most accurate, with the lowest number of patients meeting the criteria. Led to the development of the International Consensus Criteria (ICC) in 2011.

International Consensus Criteria (ICC) - A set of diagnostic criteria, based on the Canadian Consensus Criteria, that argued for the abandonment of the term "chronic fatigue syndrome" and encouraged the sole use of the term "myalgic encephalomyelitis".

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

tachycardia An unusually rapid heart beat. Can be caused by exercise or illness. A symptom of postural orthostatic tachycardia syndrome (POTS). (Learn more: www.heart.org)

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

somatic symptom disorder A psychiatric term to describe an alleged condition whereby a person's thoughts somehow cause physical symptoms. The actual existence of such a condition is highly controversial, due to a lack of scientific evidence. It is related to other psychiatric terms, such as "psychosomatic", "neurasthenia", and "hysteria". Older terms include "somatization", "somatoform disorder", and "conversion disorder". Such terms refer to a scientifically-unsupported theory that claims that a wide range of physical symptoms can be created by the human mind, a theory which has been criticized as "mind over matter" parapsychology, a pseudoscience.