POTS Symptoms, Causes, and Treatment

Postural orthostatic tachycardia syndrome (POTS) is a blood circulation disorder characterized by symptoms such as lightheadedness, headaches, vision problems, and palpitations in response to standing. With POTS, the heart rate increases dramatically with body position.

The diagnosis is based on an assessment of your blood pressure and pulse (heart rate). The effects vary in severity from relatively mild to incapacitating, and medications and lifestyle strategies can help reduce the symptoms.

POTS Symptoms

Postural orthostatic tachycardia syndrome (POTS) symptoms occur within a few minutes of standing up from a lying or seated position. The condition can cause a range of symptoms that may occur often, even on a daily basis.

The most common symptoms of POTS include:

• Lightheadedness or dizziness
• Palpitations (a sense that you have a rapid or irregular heart rate)
• Legs becoming a red-purple color (more difficult to see in people with darker skin tones)
• Blurred vision
• Weakness and/or fatigue
• Tremulousness
• Feelings of anxiety
• Headaches
• Feeling like you will almost pass out
• Sleep disturbances
• Trouble concentrating or "brain fog"

A POTS episode may look different for different people. You can experience any combination of these symptoms with POTS.

If you have POTS, you may also experience recurrent episodes of fainting, typically without any trigger besides standing up.

POTS Causes

Blood pressure and heart rate are controlled by the autonomic nervous system—the part of the nervous system that manages internal bodily functions such as digestion, respiration, and heart rate. Normally, standing up causes blood to rush from the torso to the legs. This sudden change means that less blood is immediately available for the heart to pump.

To compensate for this, the autonomic nervous system tells the blood vessels to constrict to push more blood to the heart and keep the blood pressure and heart rate normal.

Sometimes, though, the body isn't able to do this correctly. If the blood pressure drops from standing and causes symptoms like lightheadedness, it is called orthostatic hypotension. If the blood pressure stays normal but the heart rate gets faster, it is called POTS.

The exact factors that cause POTS are probably different in each person, but are related to changes in the autonomic nervous system, adrenal hormone levels, total blood volume (which can drop with dehydration), and poor exercise tolerance.

Sometimes the first episode of POTS occurs after a health event such as:

• Acute infectious illness, like as a bad case of influenza
• An episode of trauma or concussion
• Major surgery
• Pregnancy

Association Conditions

POTS is considered a type of dysautonomia, which is diminished regulation of the autonomic nervous system. POTS can be associated with other dysautonomia syndromes, like neurocardiogenic syncope.

People with POTS are often co-diagnosed with other conditions such as chronic fatigue syndrome, Ehlers-Danlos syndrome, fibromyalgia, irritable bowel syndrome, migraines, and other autoimmune and/or bowel conditions.

Diagnosis

Your diagnostic evaluation will include a medical history, a physical examination, and diagnostic tests. Your healthcare provider will take your blood pressure and pulse at least twice—once while you are lying down and once while you are standing.

Measurements of blood pressure and pulse rate lying down, sitting, and standing are referred to as orthostatic vitals.

Normally, standing up increases the heart rate by 10 beats per minute or less. With POTS, the heart rate is expected to increase by 30 beats per minute or more while blood pressure remains about the same.

In POTS, the heart rate stays elevated for more than a few seconds upon standing (often 10 minutes or more), symptoms occur frequently, and the condition lasts for more than a few days.

Diagnostic Tests

Some experts in POTS use a tilt-table test to make the initial diagnosis and monitor therapy. During this test, blood pressure and pulse are measured at several time intervals when you are lying down on a table and when the table is moved to an upright position.

Similar Conditions

You may not be able to tell you have POTS without a medical evaluation. This is because there are many causes of dysautonomia, syncope, and orthostatic hypotension. Throughout the diagnostic process, your healthcare provider may consider other conditions besides POTS, such as dehydration, deconditioning from prolonged bed rest, and diabetic neuropathy.

Medications such as diuretics or blood pressure medication can cause effects similar to those of POTS as well.

POTS Treatment

There are several important approaches used in the management of POTS and you may need a combination of several therapeutic approaches.

Your healthcare provider may suggest that you regularly check your blood pressure and pulse at home so that you can discuss the results when you go in for your medical checkups.

Fluids and Diet

Drinking non-caffeinated fluids can keep you hydrated. You and your healthcare provider can calculate the right amount of fluids that you need each day. Overnight dehydration is common, so it is especially important to drink fluids first thing in the morning (before getting out of bed, if possible).

It is also important that you maintain an adequate amount of sodium. Generally, it is extremely rare for a person to be too low in sodium, but it is a factor to be aware of.

Exercise Therapy

Exercise therapy can help your body learn to adjust to an upright position. Because it can be very difficult to exercise when you have POTS, a formal exercise program under supervision may be needed.

An exercise program for POTS may begin with swimming or using rowing machines, which do not require an upright posture. Generally, after a month or two, walking, running or cycling may be added.

Studies have shown that patients with POTS on average have smaller cardiac chambers than those without. Regular aerobic exercise has been shown to increased cardiac chamber size, slow heart rate and improve symptoms.

Medication

Prescriptions that have been used to manage POTS include midodrine, beta-blockers, pyridostigmine (Mestinon), and fludrocortisone.

Ivabradine, used for a heart condition called sinus tachycardia, has also been used effectively in some people with POTS.

Non-Pharmalogical Interventions

Other things you can do to prevent POTS include:

• Sleeping in the head-up position, which involves elevating the head of the bed off the ground 4 to 6 inches utilizing blocks of wood, books or risers. This is believed to work by increasing the volume of blood in circulation
• Performing countermeasure maneuvers, which include squatting, squeezing a ball, or crossing of the legs.
• Wearing compression stockings to prevent too much blood from flowing into your legs when you stand, potentially helping you avoid orthostatic hypotension.

Summary

POTS is a condition characterized by symptoms like lightheadedness, dizziness, heart palpitations, and fatigue. These symptoms are related to a change in body position, usually when standing up from a seated or prone position.

In people with POTS, symptoms occur because the heart rate increases dramatically with body position. POTS is a chronic condition, but it can be managed with medications and non-pharmacological interventions such as exercise therapy, compression stockings, or changes in sleeping position.