Postural Orthostatic Tachycardia Syndrome: A Consideration in Orthostatic Intolerance
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Postural orthostatic tachycardia syndrome may not be the first disorder that clinicians consider when they encounter a patient with orthostatic intolerance, but ignoring this possibility during a differential diagnosis can mean patients continue to experience unexplained dizziness, fatigue, syncope, and a variety of other related signs and symptoms. Arriving at the correct diagnosis will allow you to help patients manage the condition and return to the lives and activities they previously enjoyed.
TREATMENT
Once the diagnosis of POTS has been confirmed, symptomatic treatment tailored to the patient’s symptoms can begin. Secondary POTS often resolves with effective treatment of the causative disease. One of the most important aspects of effective treatment of primary POTS is to educate patients on how to control their symptoms. Patients must understand that primary POTS cannot be “cured” by current medical therapies. They need to be aware of the erratic symptoms and be proactive in preventing them from occurring. Both nonpharmacologic and pharmacologic treatments are helpful, but a multidisciplinary approach appears to be most efficacious for optimizing return to baseline function in patients.14,16
To prevent exacerbations, patients should avoid situations that precipitate symptoms, such as prolonged standing, inadequate water intake, and cold and hot environments. In addition, providers should advise patients to optimize their fluid status. The literature recommends adding up to 20 g of sodium to the diet daily, and patients should be instructed to drink a minimum of two liters of water during the course of the day.13,16 This includes drinking at least eight ounces of water before rising from a recumbent position. Patients should also be instructed to sleep on an incline7 and to gradually transition to standing when getting up in the morning or after a nap.12 Clinicians should also recommend waist-high graded elastic hose, an abdominal girdle, or both, to assist venous return from the lower extremities and to avoid splanchnic pooling.13
Exercise training has been shown to be effective in treating symptoms of POTS. A recent study published by Fu et al7 demonstrated improved oxygen uptake, increased blood volume, increased cardiac output, and increased left ventricular mass with graduated exercise over a period of several months. The study group demonstrated a lower average resting heart rate and improved exercise tolerance on completion of the trial. In fact, the study reported that after training, more than half of the study patients (10 of 19) no longer fulfilled the criteria for POTS, and all patients who underwent training experienced significant improvements in quality of life.7
PHARMACOLOGIC THERAPIES
Pharmacologic therapies for POTS abound. Treatments must be tailored to each patient’s needs based on the suspected or proven etiology of POTS, as well as any associated or comorbid conditions. Fludrocortisone will decrease salt loss and increase plasma volume in patients with hypovolemia. Midodrine improves vasoconstriction in the extremities. Beta-blockers slow the heart rate and prevent vasodilation. Clonidine can lower the blood pressure and decrease the heart rate by preventing central sympathetic stimulation.12 Alternatively, or in conjunction with the other treatment modalities, selective serotonin reuptake inhibitors may improve sleep, slow the heart rate,16 improve mood, and alleviate gastrointestinal symptoms. As with all medications, clinicians must discuss the risks, benefits, adverse effects, alternatives, and potential interactions with the patient prior to starting medications.
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