Postural Orthostatic Tachycardia Syndrome, also known as POTS, is a condition in which a change from a supine to an upright position causes an abnormally large increase in heart rate. This condition has interested me over the past few months after personally watching my housemate recently become diagnosed by this condition and experiencing hands-on how it can affect an individual’s lifestyle.
According to Abed and colleagues (2012), to be diagnosed with POTS, the individual must present with the following signs and symptoms;
- Heart rate increase of over 30 beats per minute from supine to standing.
- Unexplained Blood Pressure fluctuations.
- Standing plasma norepinephrine > 3.5 mmol/L.
- Light-headedness, chronic fatigue, exercise intolerance, nausea, chest discomfort etc.
The pathophysiology underlying POTS is not completely understood and is likely to be multifactorial (Wells et al., 2018). Factors such as increased sympathetic tone, severe deconditioning, moderate autonomic dysfunction and poor venous return may contribute to POTS symptoms. Poor venous return may be a result of impaired vasoconstriction secondary to several factors and concurrent clinical syndromes.
The average age for onset of POTS is approximately 30 years old with most patients between the ages of 20-40 years. This condition is commonly seen in women, with a 5:1 ratio in comparison to men (Van der Zalm et al., 2019). Although POTS is not known to shorten life, it can be physically and mentally debilitating for the patient. Therapy rarely cures it, but a multifaceted approach can substantially improve quality of life.
Treatment and Management
There is no single universal gold standard therapy and treatment for POTS. Management should be individually determined with the primary goals including restoring function and managing symptoms that persist. Graded approaches should be used, with a nonpharmacologic approach the best option before resorting to medications.
Education for any patient with a chronic health condition is vital for management. Education concerning pathophysiology and symptoms, with numerous lifestyle strategies, are aimed to reduce POTS-related symptoms. Furthermore, strategies to avoid triggers and manage symptoms are more likely to be adopted if patients understand the underlying rationale (Wells et al., 2018).
According to Lei and Colleagues (2019), increased fluid and salt intake is advisable, with 2 to 3L of water accompanied by 10 to 12g of daily sodium intake is recommended. This is to promote plasma volume expansion and reduce the reflex tachycardia upon standing.
Exercise prescription is very important in the management of POTS but should be introduced gradually as physical activity can exacerbate symptoms (Lei et al., 2019). As POTS symptoms are exacerbated from maintaining upright posture, exercise prescription should include recumbent exercises (recumbent bike, rowing etc) for 3 days a week, 30 mins a day.
Physical reconditioning with regular exercise is the cornerstone treatment for POTS, especially for an individual who has been bed ridden, resulting in cardiovascular deconditioning. A structured exercise program featuring endurance reconditioning with some resistance training for the lower body is recommended, and supervised exercise training is preferable to maximize functional capacity in these patients.
A study by Fu and Levine (2018) found that short-term exercise training increased peak oxygen uptake by 8%, cardiac size and mass by 12% and 8%, and blood volume by 6%. Other benefits include an increase in overall body strength as well as reduce fatigue.
Exercise prescription at the end of the day is a treatment and not a cure, and benefits can rapidly disappear if regular activity is stopped. If you would like more information on exercise prescription for cardiovascular conditions you can email us on firstname.lastname@example.org.
Joel Skinner (B.Sc Exercise Science and Rehabilitation)
Accredited Exercise Physiologist (AEP) (AES) (ESSAM)
Abed, H., Ball, P.A., & Wang, L-X. (2012). Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review. Journal of Geriatric Cardiology. 9, 61-67. doi: 10.3724/SP.J.1263.2012.00061
Fu, Q., & Levine, B.D. (2018). Exercise and Non-Pharmacological Treatment of POTS. Autonomic Neuroscience. 215, 20-27. doi: 10.1016/j.autneu.2018.07.001
Lei, L.Y, Chew, D.S., Sheldon, R.S., & Raj, S.R. (2019). Evaluating and managing postural tachycardia syndrome. Cleveland Clinical Journal of Medicine. 86 (5), 333-345. doi:10.3949/ccjm.86a.18002
Van der Zalm, T., Alsma, J., Van de Poll, S.W.E., Wessels, M.W., Riksen, N.P., & Versmissen, J. (2019). Postural orthostatic tachycardia syndrome (POTS): a common but unfamiliar syndrome. The Netherlands Journal of Medicine. 77 (1), 3-9
Wells, R., Spurrier, A.J., Linz, D., Gallagher, C., Mahajan, R., Sanders, P., Page, A., & Lau, D. (2018). Postural tachycardia syndrome: current perspectives. Vascular Health and Risk Management. 14, 1-11. doi.org/10.2147/VHRM.S127393