Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is a condition that causes your heart to beat faster than normal when you go from sitting or lying down to standing up. It’s a type of orthostatic intolerance.

Each word of POTS has a meaning:

• Postural: Related to the position of your body
• Orthostatic: Related to standing upright
• Tachycardia: A heart rate over 100 beats per minute
• Syndrome: A group of symptoms that happen together

Normally, your body’s autonomic nervous system balances your heart rate and blood pressure to keep your blood flowing at a healthy pace, no matter what position your body is in. If you have POTS, your body can’t balance blood vessel constriction (squeezing) and heart rate response. This means that your body can’t keep blood flow to your brain and other organs steady and stable. This causes a variety of symptoms.

Each case is different. You may see symptoms come and go over a period of years. In most cases, changes in diet, medications and physical activity can improve quality of life.

POTS is fairly common. It affects over 500,000 people in the United States alone. Most people with POTS are females aged 15 to 50 years. But males can also have the syndrome.

Symptoms of POTS

You can develop POTS suddenly or gradually. Symptoms happen immediately or a few minutes after sitting up or standing. Lying down may help them go away.

POTS has several possible symptoms, and they vary from person to person. They may include:

• Dizziness or lightheadedness, especially when standing up, during prolonged standing or on long walks
• Fainting or near fainting
• Brain fog
• Heart palpitations or racing heart rate
• Exhaustion and fatigue
• Feeling nervous or anxious
• Shakiness and excessive sweating
• Shortness of breath
• Chest pain
• Headaches
• Feeling sick
• Bloating
• A pale face and purple discoloration of your hands and feet
• Disrupted sleep from chest pain, racing heart rate and excessive sweating

Symptom triggers

Certain situations can trigger POTS symptoms or make them worse, like:

• Being in warm environments, like taking a hot bath or shower or being outside on a hot day
• Standing frequently, like when you’re waiting in line or shopping
• Strenuous exercise
• Being sick
• Being on your period

POTS causes

Researchers aren’t sure what causes POTS. Multiple factors may lead to it. They’ve grouped POTS into different types, including:

• Neuropathic POTS: Peripheral denervation (loss of nerve supply) leads to blood pooling, especially in your legs and core.
• Hyperadrenergic POTS: Your sympathetic nervous system (“fight-or-flight” response) is overactive.
• Hypovolemic POTS: You have less blood than typical. Low blood volume can cause similar symptoms that may overlap in neuropathic and hyperadrenergic POTS.

Researchers are still learning about this condition. There’s growing evidence that the syndrome might be an autoimmune disease. A few studies have also looked at a potential genetic cause of POTS. They found a change in the SLC6A2 gene that may play a role.

Risk factors

You’re at higher risk of developing POTS if you have:

• Biological family history of POTS
• Certain autoimmune conditions, like Sjögren’s syndrome, lupus and celiac disease
• Ehlers-Danlos syndrome type III (also called hypermobile Ehlers-Danlos syndrome)

The following stressors may trigger the development of POTS:

• Significant illnesses, such as viral illnesses, like mononucleosis or COVID-19
• Pregnancy
• Physical trauma, such as a head injury
• Surgery

Complications of this condition

While POTS isn’t life-threatening, it can greatly interfere with daily living and tasks. Simple activities, like showering, standing to cook or walking up stairs, can trigger symptoms.

The biggest physical risk is getting hurt if you faint and fall.

How doctors diagnose this condition

POTS can be difficult to diagnose due to the many symptoms that can occur over time. You may have symptoms for months to years before finally being diagnosed with the condition.

A healthcare provider will ask questions about your symptoms, medications and medical history. They’ll also do a physical exam.

A tilt table test is the main way providers diagnose POTS. It measures your heart rate and blood pressure as you change posture and position.

Your provider may suggest other tests to help confirm a POTS diagnosis or rule out other possible causes of your symptoms. These tests include:

• Blood and urine tests for causes of POTS and conditions that mimic it
• QSART, which measures the autonomic nerves that control sweating
• Autonomic breathing test, which measures your blood rate and pressure response during exercise
• Skin biopsy, which can help identify neuropathic causes of POTS

How is it treated?

There’s no cure for POTS. Instead, healthcare providers use several strategies to manage the symptoms. They tailor the treatment plan based on your symptoms and what works best for you.

The main forms of treatment include physical activity and nutrition changes. Compression therapy can also help push blood up from your legs to help reduce symptoms.

Physical activity

Exercise and physical activity are key to managing POTS.

Your provider may recommend a cardiac rehab program (even if you have a healthy heart). This exercise program helps recondition your cardiovascular system. Some of the best data for treating POTS comes from cardiac rehab.

Reclined aerobic exercises, like swimming, rowing and recumbent bicycling, are often the most beneficial. Strengthening your core and leg muscles also helps.

Your provider will give you specific instructions. But here are some things to keep in mind as you start to move your body:

• Do isometric exercises. Contract your muscles without moving your body. Squeezing your muscles helps push your blood back toward your heart. You can do these exercises lying in bed or seated. Doing them in bed before getting up can prepare your body for sitting and standing.
• Transition slowly with your body. Give your body time to adjust to moving positions. For example, go from lying to sitting on the edge of your bed. Stay there for several minutes. Once you’re standing, pause and wait before walking to allow your blood pressure to adjust.
• Begin a modest walking program. Count how many steps you can do without causing symptoms. These steps are your initial baseline. Gradually increase the number of steps over time.

Diet and nutrition

Adjusting how you eat and drink is another important part of managing POTS symptoms.

If you have the hypovolemic (low blood volume) form of POTS, your healthcare provider may suggest increasing your fluid and salt intake. This increases the amount of blood in your body.

Eating a large meal can make symptoms of POTS worse. This is because your body redirects a lot of blood to aid in digestion. So, providers often recommend eating several smaller meals throughout the day instead of two or three large ones.

A dietitian can help you with an eating plan. General guidelines for dietary changes include:

• Increase sodium (salt) in your diet from 3,000 milligrams (mg) to 10,000 mg per day.
• Drink 2 to 2.5 liters of fluids per day. Water is the best choice.
• Choose beneficial salty snacks, like broth, pickles, olives, sardines and nuts. Don’t over-rely on snack chips and crackers for salt.
• Avoid alcohol. It can worsen symptoms, as it dehydrates you.

Sleep management

POTS can disrupt your sleep. Because sleep is very important for overall health, you should prioritize it.

It may help to raise the head of your bed six to 10 inches to help alleviate symptoms. The entire bed must be at an angle. Raising the head of the bed will increase fluid volume in your circulation in the morning. This may help you wake up more easily.

Practicing proper sleep hygiene can also help. Talk to your provider if POTS is significantly disrupting your sleep.

Medications

The U.S. Food and Drug Administration (FDA) doesn’t approve any medications for POTS treatment. But providers sometimes prescribe medications to help certain symptoms.

These medications may include:

• Fludrocortisone (increases salt retention and blood volume)
• Pyridostigmine (may reduce tachycardia)
• Midodrine (leads to widespread vasoconstriction)
• Beta-blockers (may reduce upright tachycardia)

All these medications have potential side effects. Your provider will work with you to see if medication is right for you.

What can I expect if I have this condition?

The prognosis (outlook) is generally good. People with POTS have a typical life expectancy. But it can severely disrupt daily living. This can take a toll on your mental health.

POTS symptoms may come and go for years. In about 8 out of 10 cases, the condition improves. But many people have symptoms that remain.

No two people with POTS are affected in the same way. So, it may take time to figure out what treatments work for you. Having a care team that specializes in POTS can help.

Is there anything I can do to feel better?

Postural orthostatic tachycardia syndrome can be challenging to live with. Here are some things you can do to help take care of yourself:

• Monitor your pulse and blood pressure. This can provide insight into your case and help your healthcare provider fine-tune your treatment.
• Be open and honest with loved ones. Talk about your fears, hopes, struggles and challenges with the condition.
• Join POTS support groups. Relating to others can help you feel less alone.
• Be cautious of quick solutions. Quick fixes from nonmedical sources usually don’t help POTS. They can lead to more emotional distress.
• Consider talk therapy. A therapist can help you learn to cope with this chronic condition.

Preventing flare-ups

Knowing your triggers can help you manage POTS. Some general guidelines for preventing flare-ups include:

• Maintain a consistent temperature. Extremes, especially heat, can make symptoms worse. Air conditioning, cooling vests, handheld misters, personal fans and wearing layers in case of temperature fluctuations can all help. When showering, try to use lukewarm water.
• Avoid prolonged standing. If you must stand for a long time, try flexing and squeezing your feet and muscles or shifting your weight from one foot to the other.
• Manage stress. Try meditation, yoga or breathing exercises to help manage stress.