Postural Orthostatic Tachycardia Syndrome (POTS)

What is postural orthostatic tachycardia syndrome (POTS)?

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

Each word of “postural orthostatic tachycardia syndrome” 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 coordinate the balancing act of blood vessel constriction (squeezing) and heart rate response. This means that your body can’t keep your blood pressure steady and stable. This causes a variety of symptoms.

Each case of POTS is different. People with POTS may see symptoms come and go over a period of years. In most cases, with adjustments in diet, medications and physical activity, a person with POTS will experience an improvement in their quality of life.

Who does POTS affect?

The majority of people with POTS are women and people assigned female at birth aged 15 to 50 years. But men and people assigned male at birth can also have POTS.

You’re at a higher risk of developing POTS after experiencing the following stressors:

• Significant illnesses, such as viral illnesses like mononucleosis or serious infections.
• Pregnancy.
• Physical trauma, such as a head injury.
• Surgery.

People who have certain autoimmune conditions, such as Sjogren’s syndrome, lupus and celiac disease, are also more likely to develop POTS.

How common is POTS?

POTS is common. It affects about 1 to 3 million people in the United States.

How does postural orthostatic tachycardia syndrome (POTS) affect my body?

Normally, when you stand up, gravity causes about 10% to 15% of your blood to settle in your abdomen, legs and arms. This means that less blood reaches your brain, which can cause brief lightheadedness. If you don’t have POTS, this lightheaded feeling doesn’t happen often because your leg muscles help pump blood back up to your heart.

In addition, your autonomic nervous system turns on a series of rapid responses. To compensate for the lower amount of blood returning to your heart after standing up, your body releases the hormones epinephrine (adrenaline) and norepinephrine.

These hormones typically cause your heart to beat a little faster and with more force. Norepinephrine also causes your blood vessels to tighten or constrict. This all results in more blood returning to your heart and brain.

People with POTS tend to pool a larger amount of blood in vessels below their heart when they stand. Their body responds by releasing more norepinephrine or epinephrine to try to cause more squeezing of their blood vessels. For several reasons, their blood vessels don’t respond normally to these hormones. Because their heart remains able to respond to the norepinephrine and epinephrine, their heart rate often increases.

This imbalance causes many possible symptoms, such as dizziness, fainting and exhaustion.

Is POTS a serious condition?

While POTS isn’t life-threatening, it can greatly interfere with daily living and tasks. The good news is that a variety of treatments and strategies can help improve symptoms.

What are the symptoms of POTS?

You can develop POTS suddenly or it can develop gradually.

Symptoms happen immediately or a few minutes after sitting up or standing. Lying down may relieve some of the symptoms.

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

• Dizziness or lightheadedness, especially when standing up, during prolonged standing in one position or on long walks.
• Fainting or near fainting.
• Forgetfulness and trouble focusing (brain fog).
• Heart palpitations or racing heart rate.
• Exhaustion/fatigue.
• Feeling nervous or anxious.
• Shakiness and excessive sweating.
• Shortness of breath (dyspnea).
• Chest pain.
• Headaches.
• Feeling sick.
• Bloating.
• A pale face and purple discoloration of your hands and feet if they’re lower than the level of your heart.
• Disrupted sleep from chest pain, racing heart rate and excessive sweating during sleep.

POTS symptoms often get worse in the following situations:

• Being in warm environments, such as in a hot bath or shower or on a hot day.
• Standing frequently, such as when you’re waiting in line or shopping.
• Participating in strenuous exercise.
• When you’re sick, such as from a cold or an infection.
• Having your period (menstruation).

What causes POTS?

Researchers aren’t sure yet what exactly causes POTS. Currently, they think there are multiple causes, which they’ve grouped into different subtypes of POTS, including:

• Neuropathic POTS: This happens when peripheral denervation (loss of nerve supply) leads to poor blood vessel muscles, especially in your legs and core (abdomen).
• Hyperadrenergic POTS: This happens when your sympathetic nervous system is overactive.
• Hypovolemic POTS: Reduced blood volume can lead to POTS. Low blood volume can cause similar symptoms that may overlap in neuropathic and hyperadrenergic POTS.

There’s also growing evidence suggesting that POTS might be an autoimmune disease, meaning your immune system attacks healthy tissue for unknown reasons.

How is postural orthostatic tachycardia syndrome (POTS) diagnosed?

POTS can be difficult for healthcare providers to diagnose due to the many symptoms that can occur over time. People with POTS 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 perform a physical exam.

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

Besides the tilt table test, your provider may order other tests to help confirm a POTS diagnosis or rule out other possible causes of your symptoms, including:

• Blood and urine tests for causes of POTS and conditions that mimic POTS.
• QSART (a test that measures the autonomic nerves that control sweating).
• Autonomic breathing test (this measures your blood rate and pressure response during exercise).
• TST (tuberculin skin test).
• Skin nerve biopsy.
• Echocardiogram.
• Blood volume with hemodynamic studies.

What is the treatment for postural orthostatic tachycardia syndrome (POTS)?

Unfortunately, there’s no cure for POTS. Instead, healthcare providers use several strategies to manage the symptoms of POTS. Treatment is highly individualized based on your symptoms and what works best for you.

The main forms of treatment include:

• Exercise and physical activity.
• Diet and nutrition.

Medical compression stockings can also help push blood up from your legs to reduce POTS symptoms.

Exercise and physical activity

Exercise and physical activity are key to managing POTS.

Although most people with POTS have healthy hearts, your provider may recommend a cardiac rehab program. This exercise template uses the cardiac rehab model to recondition and help improve health and manage POTS. Some of the best data for treating POTS comes from cardiac rehab.

Studies show that reclined aerobic exercise, such as swimming, rowing and recumbent bicycling, has the best results. Strengthening your core and leg muscles is also helpful.

Here are important things to know as you undergo an exercise program and other physical activities. Talk with your provider for specific instructions on these exercises.

• Practice isometric exercises: These exercises involve contracting your muscles without actually moving your body. Isometrics squeeze your muscle and push your blood back toward your heart. They’re simple to do, and you can do them lying in bed or seated. It’s a good idea to do these in bed before getting up to prepare your body for sitting and standing.
• Transition slowly with your body: Go from lying to sitting on the edge of your bed. Stay there for several minutes, allowing your body to naturally adjust to the change in position. Once you’re standing, pause and wait before walking to allow your blood pressure to adjust again. If you feel lightheaded at any point, wait for a few minutes in that position to see if it resolves. If not, then return to the prior position. Moving slowly is the key.
• Begin a modest walking program: Count how many steps you can do without causing symptoms. These steps are your initial baseline. Start with walking once a day and go a little farther in time, distance or by adding steps. If you feel good, add a second walk in the day. A simple strategy for counting steps is to do 100 to 300 steps per hour during the day. Fitness trackers can monitor steps easily. Every week or every few weeks, add more steps to your daily total.
• Practice simple yoga: Practicing basic yoga with a focus on breathing may help reduce POTS symptoms.

Diet and nutrition

Managing diet and nutrition is another important aspect of managing POTS symptoms.

If you have the hypovolemic (low blood volume) form of POTS, your healthcare provider will likely recommend increasing both your fluid and salt intake to increase blood volume.

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

A nutritionist or dietitian can help you with your diet. This consult can be especially helpful if you have celiac disease or other dietary sensitivities.

General guidelines for dietary changes include:

• Increase sodium in your diet from 3,000 milligrams (mg) to 10,000 mg per day.
• Drink 2 to 2.5 liters per day of fluids. Water is the best choice.
• Eat small and frequent meals instead of a few large meals.
• Eating a diet with high fiber and complex carbohydrates may help reduce blood glucose (sugar) spikes and lessen POTS symptoms.
• Keep your nutrition balanced with protein, vegetables, dairy and fruits.
• Choose beneficial salty snacks such as broth, pickles, olives, sardines, anchovies and nuts. Don’t over-rely on snack chips and crackers for salt.
• Plan grocery store shopping using a list to make sure you pick up healthy food choices and POTS care (hydration and salty supplements). If you have low stamina, have someone help you shop and carry and put away your groceries.

Medications

The U.S. Food and Drug Administration (FDA) hasn’t approved any medications for POTS treatment. But healthcare providers sometimes prescribe medications off-label to help certain POTS symptoms.

These medications include:

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

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

What can I do to manage postural orthostatic tachycardia syndrome?

Aside from exercise and dietary changes, other things you can do to manage POTS include frequently monitoring your pulse and blood pressure and getting quality sleep.

Monitoring pulse and blood pressure

Taking and writing down your blood pressure and pulse can provide insight into POTS and helps your healthcare provider fine-tune your treatment.

Check your blood pressure and pulse at the same time daily (in the morning and after dinner). It’s very helpful to do this for the first few months of your diagnosis. Also, check your blood pressure and pulse when you aren’t feeling well.

You can get a blood pressure monitor at most drug stores, online or at a medical supply store

Managing sleep with POTS

POTS can disrupt your sleep. As sleep is very important for overall health, you should prioritize it. These general guidelines may help you:

• Raise the head of your bed six to 10 inches to help alleviate POTS 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.
• Make sure the temperature is ideal in your bedroom to help you get proper rest.
• Try to maintain a typical sleep schedule. Go to bed consistently at a certain time and set a consistent time to wake up. The best sleep hygiene and good rest come from staying consistent with your sleep schedule every day.
• Avoid excessive daytime napping. It may make nighttime sleep less restful.
• Avoid excessive television viewing or using your phone or computer in bed. These technologies can interfere with sleep quality.

Talk to your provider if POTS is significantly disrupting your sleep.

Can postural orthostatic tachycardia syndrome be prevented?

Unfortunately, there’s nothing you can do to prevent developing POTS. But there are steps you can take to try to prevent flare-ups by knowing what your triggers are.

Some general guidelines for preventing flare-ups include:

• Maintain a consistent temperature: It’s important for people with POTS to maintain an even temperature, as 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, as either hot or cold can trigger POTS symptoms. Using a shower chair can also be helpful.
• Avoid prolonged standing: Standing for a long time makes symptoms worse for most people with POTS. 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.
• Avoid alcohol: Alcohol can worsen symptoms because it dehydrates your body.

What is the prognosis for postural orthostatic tachycardia syndrome (POTS)?

The prognosis (outlook) for POTS is generally good, although it can severely disrupt daily living. POTS symptoms may come and go for years. In approximately 80% of cases, the condition improves, but many people have residual symptoms.

The biggest risk to people with POTS is getting hurt if they faint and fall.

What is the life expectancy of POTS?

People with POTS have a normal life expectancy. The condition doesn’t decrease life expectancy.

How do I take care of myself if I have POTS?

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

• Be open and honest with loved ones about your diagnosis of POTS. Talk about your fears, hopes, struggles and challenges with the condition. Encourage the people who support you to learn more about POTS.
• Get enough sleep and eat well to help manage stress.
• Consider attending POTS support groups (either online or in-person). They can help reduce the feeling of being alone.
• Be very cautious of quick solutions from nonmedical sources and people. Quick solutions usually don’t help POTS and can even cause more emotional distress.
• Consider counseling (psychotherapy) to help you learn to cope with a chronic health condition. Counseling may help manage other coexisting mental health conditions that may negatively influence POTS.
• Meditate or take even just a few minutes of a time-out to help reduce some of your POTS symptoms.
• Emotions can have a significant influence on your daily life and health. Identifying them can be useful if you’re talking with a counselor or POTS support group.

When should I see my healthcare provider about POTS?

If standing up causes unusual symptoms, such as lightheadedness and a pounding heart rate, see a healthcare provider.

If you have POTS, try to see a healthcare provider who specializes in POTS to get the best care. You’ll also need a primary care physician to go to for routine care and health wellness management.

A note from Cleveland Clinic

Learning that you have postural orthostatic tachycardia syndrome (POTS) can be overwhelming. Know that there are several treatments and lifestyle adaptations that can help manage your symptoms. No two people with POTS are affected in the same way, so it’s important to receive individualized care that’s unique to your situation. Don’t be afraid to ask your healthcare provider questions about POTS. They’re available to help you.