POTS
Postural Orthostatic Tachycardia Syndrome
Lorna Busmer
Nurse Practitioner
Rotherham
Definition
•
Increase heart rate of > 30 bpm within 10 min of standing
•
The standing heart rate is often > 120 bpm
•
Without hypotension
•
Low resting heart rate
•
Aged 12–19 years- increment of > 40 bpm
(Freeman et al 2011)
POTS
• Incidence in the UK unknown
• Increased frequency in females
• Often misdiagnosis
• Many given anxiety diagnosis
• 25-50% of people with CFS may have POTS Hoad et al 2008
Case Study 1
• Female health professional in 30s
• Symptoms
– Fatigue
– exercise intolerance
– relieved by sitting down
• PMH – tachycardia
• ECG – Normal sinus rhythm
• 24 hour tape – Sinus Rhythm with heart rates up to 150 bpm
Case Study 1 Cont.
• 1st Diagnosis - Anxiety and depression
• 2nd diagnosis – Inappropriate sinus tachycardia (IST)
• Further investigations
– tilt test - drop in BP on tilt after 40 minutes
– autonomic function test
• Supine HR 90 bpm
• Standing HR 126
• 3rd diagnosis – POTS, IST, Vasovagal syncope (VVS)
• Meds – Diltiazem, Sertraline
160
140
REST
HEART RATE
120
AFTER 5 mins of
standing
100
After getting
dressed
80
60
40
20
0
1
2
3
4
5
6
Day
7
8
9
10
Case Study 2
• Female health care professional - 50s
• Symptoms over 20 years
–
–
–
–
–
–
–
–
–
Dizziness (20 years hx)
Fatigue
Nausea
Diarrhoea
Headaches
Palpitations
sweating
Tremulous
collapse
• PMH – Recurrent musculoskeletal problems, migraine
Case Study 2 Cont.
• 1st diagnosis – Inner ear/Balance problem
• 2nd diagnosis - Benign positional vertigo, irritable bowel
syndrome and anxiety
• 3rd diagnosis – JHS, POTS, VVS
• Treatment - Fludrocortisone, midodrine, beta blockers, SSRIs
Symptoms
CARDIOVASCULAR
Lightheaded
Dizziness
Rapid Heart rate
Palpitations
Near fainting or fainting
Short of breath
Chest Pain
GASTROINTESTINAL
Nausea
Diarrhoea
Abdominal cramps
Constipation
Bloating
NEUROLOGICAL
Headaches
Tremulous
MUSCULAR SKELETAL
Restless Leg syndrome
Myofascial pain
Neuropathic pain
GENERAL
Fatigue
Tiredness
Weakness
Exercise intolerance
OTHER
Excess Sweating
Loss of sweating
Bladder problems
Sleep disturbance
Onset
• Sudden or gradual
• After
– Virus/febrile illness
– Trauma
– Pregnancy
– Surgery
Severity
• Mild, moderate, severe
• 25% of patients may be unable to work and be wheel
chair dependant
• Disability can be equivalent to that found in heart
failure
(Benrud-Larson et al 2002)
Autonomic Nervous System
Disorders of the ANS
Reflex
Syncope
POTS
Autonomic
Failure
POTS
Primary
JHS
Partial
Dysautonomia
Developmental
Secondary
Hyperadrenergic
Hypovolemia
Other
Deconditioning
Overlapping Syndromes
IST
POTS
CSF
Recognition in primary care
• Good history
• Stand test
• Acrocyanosis
• Secondary causes
• Refer - cardiologist
Investigations
Investigations
• Stand test / Tilt Table Test
• Bloods – FBC, Ferritin, UE, LFT, TFT
• Bloods - Lying and standing Noradrenaline
• Urinary Catecolamines (Pheochromocytoma)
• Urinary sodium
• ECG/ 24 hour monitoring
• Echo
Treatment
Treatment – Non pharmacological
• Fluids
• Salt (except in H.Pots)
• Compression stockings
• Counter manoeuvres
• Psychological support
and.......
Exercise
Pharmacological
• Trial and error
• Tiny doses
• Lack of research
• Off licence
Pharmacological
• Fludrocortisone
• Midodrine
• Ivabradine
• Beta Blockers- Propranolol, Bisoprolol
• SSRI/SNRI – Sertraline, Duloxetine
• Clonidine
• Octreotide
Psychological Support
Working together with individuals, families and medical
professionals to offer information and support on syncope,
reflex anoxic seizures and POTS
www.stars.org.uk
www.stars-international.org
info@stars.org.uk
Helpline: 01789 450 564