POTS - the 4 pillars of management
POTS stands for Postural Orthostatic Tachycardia Syndrome. This means that patients with this condition find that they feel unwell with symptoms of tremulousness, dizziness and heart palpitations when they stand up. On objective assessment,there is an exaggerated and sustained increase in heart rate ( more than 30 beats/ per minute in adults; more than 40 beats per minute in children) compared to when the patient is lying down.
Healthcare professionals around the world have therefore started seeing POTS as a condition that is only manifest when the patient stands up. As our understanding and experience has improved, it is now clear that POTS is not just a condition that manifests when patients stand. Virtually all patients complain of other debilitating symptoms even when they are not upstanding. These symptoms include:
Severe fatigue
Lack of refreshing sleep
Chest pains
Breathlessness
Brain fog
Temperature dysregulation
Pain
Gut symptoms including nausea, bloating, slow transit constipation and even diarrhoea.
In this sense, the term POTS is too restrictive to capture all patients who suffer from the symptoms of POTS especially as symptoms can vary from day to day and not all patients with this condition will consistently have the obligatory exaggerated rise in heart rate to confirm the diagnosis. This is why I believe that a better term for this condition is dysautonomia which basically means a disequilibrium between the ‘flight and fight’ and ‘rest and digest’ systems of the body. Patients with this condition will complain of always being in ‘flight and fight’ mode and rarely in ‘rest and digest’ mode. They always feel tired AND wired.
The diagnosis of dysautonomia can easily be made by listening to the patient's history and if they describe the symptoms above and if they find that some of their symptoms are made worse when they are standing up then a diagnosis of POTS/dysautonomia can be entertained and this may then be confirmed by doing a tilt test. Whilst a tilt test can help confirm the diagnosis, I do not believe that a negative tilt test reliably excludes the diagnosis.
I think there are 4 pillars to the management of POTS/dysautonomia and all four should be undertaken simultaneously to hasten recovery. I list them below:
Lifestyle modification - I have previously made a comprehensive video on the type of lifestyle changes that can help symptoms. This can be accessed on my youtube channel / yorkcardiology .
Medications: The aim of medications is two-fold:
To reduce the standing heart rate - Medications that can help with this include: beta blockers and Ivabradine (in general Ivabradine is much better suited to this than beta blockers but there are some patient groups in whom beta blockers will be preferred e.g pregnant women/children)
To increase the circulating plasma volume and venous return of blood to the heart (these include medications like Fludrocortisone and Midodrine).
3) Physiotherapy - this is vital as many patients with POTS become extremely deconditioned which makes their symptoms a lot worse. Regular physiotherapy can be as effective as medications at improving symptoms and overall quality of life.
4) Social/ work-place based adjustments/rehabilitation - Once a diagnosis of POTS is made, your doctor should become your advocate and liaise with your employers/schools etc to facilitate adjustments such as flexible working, late starts etc to help you go back to your normal life without compromising on your health.
I hope you find this helpful. More on POTS can be found on my YouTube channel: / yorkcardiology
Keywords: POTS; long COVID; dysautonomia; postural orthostatic tachycardia syndrome; yorkcardiology
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