POTS is a clinical syndrome characterized by an increase in heart rate of greater than 40 beats per minute (bpm) in adolescents 12-19 years of age when moving from a lying to a standing position, the absence of low blood pressure (greater than 20 mm Hg drop in systolic blood pressure), and frequent symptoms of palpitations, lightheadedness, dizziness, near fainting and fatigue. The standing heart rate of patients with POTS is often greater than 120 beats per minute (bpm).

Onset of symptoms is usually in early adolescence, between 12-15 years of age, and more than 75% are female. More than half of cases are preceded by an acute viral illness. Other triggers may be injury (concussion), surgery, puberty or growth spurts.

POTS: Why Does This Happen? 

During position changes, gravity pulls approximately 20% of the circulating blood volume down to the lower extremities. In response to this position change, blood vessels constrict to increase circulating blood volume and increase blood return to the heart.   

Patients with POTS experience poor blood vessel constriction during position changes. This leads to blood pooling in the lower extremities. Blood pooling in the lower extremities results in decreased blood flow to the heart, brain, lungs, and abdomen. When there is low circulating blood volume, it may cause the heart rate to increase rapidly (tachycardia) to compensate.

What Are the Symptoms of POTS?

Symptoms have usually persisted for at least 3-6 months prior to the diagnosis. 

• Palpitations or rapid heart rate (tachycardia)
• Postural dizziness, lightheadedness or visual changes (blurred vision, black out vision or tunnel vision)
• Near fainting or fainting (syncope)
• Headaches
• Shortness of breath with light activity, climbing stairs or when standing for long periods of time
• Chest discomfort/pain/pressure
• Cognitive impairment or “brain fog”
• Gastrointestinal symptoms: nausea, abdominal pain, bloating, constipation or diarrhea
• Fatigue
• Exercise intolerance
• Musculoskeletal pain and chronic aches/pains
• Poor sleep

How Is POTS Managed?

Management of POTS symptoms is aimed at increasing circulating blood volume and enhancing blood return to the heart. Initial management of POTS includes exercise, hydration and nutrition. With early intervention and lifestyle changes, significant improvement in symptoms can occur within months.  

Exercise: 

• Exercise is an effective intervention for managing symptoms of POTS.
• Exercise increases circulating blood volume and reduces blood pooling in the lower extremities.
• Lower body muscles act as a pump when they contract to increase blood return to the heart.

Hydration:

• Hydration is essential to maintain circulating blood volume.
• Hydration: In patients with POTS, water intake should be more than typical daily fluid recommendations.
• Hydration goal of 80-100 ounces of water daily.
  • Water intake should be distributed evenly throughout the day.
  • Keep a bottle of water at the bedside and drink 16-20 ounces before getting out of bed in the morning.

Nutrition:

• Sugar and processed foods contribute to poor blood vessel constriction during position changes.
• Eat a variety of vegetables, fruits, fiber rich whole grains, and lean protein sources.
  • Lean protein sources include lean meats, fish, low fat/fat free dairy, lentils, nuts or nut butters, plant-based protein products, and eggs.
• Limit processed foods and sugar sweetened beverages.
  • Processed foods typically come in a box or bag and contain more than one item on the list of ingredients.
• Healthy salty snacks, such as nuts, nut butters, popcorn or homemade trail mix, may be beneficial.

What Are the Long-term Effects of POTS?

Most patients with the onset of POTS symptoms during adolescence tend to experience marked improvement in their symptoms by 19-21 years of age.