Postural Orthostatic Tachycardia Syndrome

Aka: Postural Orthostatic Tachycardia Syndrome, POTS Syndrome

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II. Definitions

  1. Postural Orthostatic Tachycardia Syndrome (POTS)
    1. Symptoms of Orthostatic Intolerance with Tachycardia, but not significantly hypotensive

III. Epidemiology

  1. Prevalence: 0.2 to 1% in general U.S. population
  2. Age <50 years in most cases (peaks age 15 to 25 years)
  3. Gender: Female to male ratio 5:1

IV. Symptoms

  1. See Orthostasis
  2. Symptoms occur on standing from supine (or seated position) and are relieved on returning to supine position
  3. Typically worse in mornings and chronic (duration 3-6 months) at diagnosis
  4. Dizziness or Light Headedness
  5. Chest Pain or Palpitations
  6. Orthostatic Syncope
  7. Nausea
  8. Pallor
  9. Weakness or Fatigue
  10. Dyspnea
  11. Blurred or dimmed Vision
  12. Neck or Shoulder Pain

V. Diagnosis

  1. Symptoms suggestive of Orthostasis (see above) AND
  2. Insignificant change in systolic Blood Pressure (BP decreases <20 mmHg) AND
    1. Does not meet criteria for Orthostatic Hypotension
  3. Tachycardia
    1. Sustained Heart Rate 30 bpm or higher within 10 minutes of standing (or Head-Up Tilt-Table Testing)
    2. Standing Heart Rate is typically >120 bpm
    3. When evaluating, age 12 to 19 year olds, requires Heart Rate increase >=40 bpm

VI. Differential Diagnosis

  1. Neurocardiogenic Syncope
  2. Orthostatic Hypotension

VII. Evaluation

  1. Head-Up Tilt-Table Testing

VIII. Management

  1. See Orthostatic Hypotension
  2. Maintain adequate hydration
  3. Aerobic Exercise
    1. Combats deconditioning with increased Cardiac Function and autonomic regulation
    2. Start with seated or horizontal Exercises first (e.g. recumbent bike, swimming, rowing machine)
    3. CHOP Modified Dallas/Levine Protocol
      1. https://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
      2. Modified Levine protocol for younger patients
    4. Levine Protocol
      1. Seven month protocol of Exercise (recumbent warmup, moderate exertion, and cooldown)
  4. Other measures
    1. Sleep in head up position
      1. Expands Blood Volume
    2. Lower body compression garments
      1. Reduces venous pooling
      2. Should extend at least to the xiphoid (or with an abdominal binder)
    3. Physical countermeasure maneuvers
      1. Squeezing a Rubber ball
      2. Leg crossing
      3. Muscle pumping
      4. Squatting
      5. Negative-pressure breathing

IX. Resources

  1. Exercise with POTS: Dallas Protocol, Levine Protocol, and CHOP Protocol
    1. https://www.eds.clinic/articles/exercise-pots-dallas-levine--chop-protocols

X. References

  1. Kim (2022) Am Fam Physician 105(1): 39-49 [PubMed]
  2. Levine (2018) Auton Neurosci 215:20-7 +PMID: 30001836 [PubMed]

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