Editor’s note: Second in a two-part series on postural orthostatic tachycardia syndrome (POTS). Click
here
for the first part.
Most of us don’t hesitate to stand up. Yet in people affected by a disorder called postural orthostatic tachycardia syndrome (POTS), simply standing can cause dizziness and a racing heart rate. This article discusses diagnosis, treatment, and living with POTS.
How is POTS diagnosed?
Measuring blood pressure and heart rate while lying down and then while standing (orthostatic vital signs) can help cardiologists like me diagnose POTS. Within 10 minutes of standing, heart rate increases by at least 30 beats per minute (bpm) in POTS mode and, most importantly, blood pressure remains stable (systolic blood pressure does not drop more than 20 mm Hg ).
These findings, along with symptoms of orthostatic intolerance (most commonly dizziness and fatigue), must be present for at least three to six months for a person to be diagnosed with POTS. Because many doctors are unfamiliar with POTS and there is no laboratory test to confirm it, patients often experience symptoms for several years before being diagnosed.
So, when David, a firefighter, came to my office, we measured his heart rate and blood pressure while lying down and then standing. When he was lying flat, his heart rate and blood pressure were normal and he felt fine. However, after just three minutes of standing, he began to feel dizzy. His heart rate increased by 35 bpm without a significant drop in his blood pressure. David had POTS.
How is POTS treated?
Although some people with POTS will need medication, most will improve with just three behavioral changes: higher sodium (salt) intake, compression garments, and gradual exercise.
Add sodium to your diet
One of the reasons people with POTS feel dizzy when standing is insufficient circulating blood volume. Drinking more fluids will help, but the key to keeping fluids flowing is sodium.
For reasons that are not fully understood, many people with POTS need up to three times more sodium than the standard limit recommended by the American Dietary Guidelines, which is 2,300 milligrams per day (about 1 teaspoon of salt). Some of my patients can consume so much sodium by eating salty foods like tomato juice, broth, pickles, and olives. Others prefer to consume high-sodium electrolyte drinks or take salt tablets.
David chose to start with a glass of tomato juice each morning (about 500 mg of sodium) and a 1 gram salt tablet at lunch, in addition to adding salt to his meals. Although David could easily meet his sodium needs by eating highly processed junk foods, I recommended he avoid them due to their low nutritional value.
Wear compression garments
Compression garments push blood into deeper veins, preventing it from pooling in the superficial veins of the lower legs. This is especially important during periods of standing, to help the body overcome the force of gravity.
There are many types of compression garments, including knee-high socks or footless calf sleeves, leggings, and bike shorts. A recent study showed that wearing a belt-like garment called an abdominal binder and knee-length compression socks works best for people with POTS. David opted for a pair of compression bike shorts and compression socks.
Gradually intensify the exercise
The cornerstone of POTS treatment is slow, consistent, and gradual return to exercise. Like many of my previously active patients, David became discouraged after experiencing fatigue and dizziness that worsened when he attempted to return to normal physical activity.
What helped? Patience combined with a “start low and go slow” approach, starting with gentle ground exercises and slowly progressing to an upright activity such as walking. In David’s case, I also recommended an additional 500 mg of sodium one hour before exercise. This helps compensate for the increased blood volume diverted to the muscles and the sodium lost in sweat.
Are there other helpful strategies for POTS?
Yes. In addition to salt, compression and exercise, I recommended David try
- place a small board under your mattress which raises the head of your bed a few centimeters
- using a symptom tracker smartphone app to help identify POTS symptom triggers
- avoid identified triggers, such as skipping meals; insufficient sleep; alcoholic beverages; hot baths and saunas; and meals high in carbohydrates.
When avoiding triggers is not possible, it helps to learn to anticipate and manage symptoms. For example, in hot, humid weather, cooling vests or scarves can help reduce symptoms. Catching a cold or an upset stomach can also cause symptoms to flare up, and many women find that symptoms get worse in the days before their period. During these vulnerable times, a person may need to intensify their salt and compression routines and, if necessary, take a day off from exercising.
Are there medications that might help?
Some people feel that behavioral changes need to be combined with medication to properly treat their symptoms. Currently, no medications have been approved by the FDA to treat POTS. However, several medications can be prescribed off-label if necessary. Your doctor may suggest one or more of the following:
- fludrocortisone (helps the kidneys retain sodium)
- midodrine (causes blood vessels to tighten)
- beta blockers (slow heart rate)
- pyridostigmine (increases neurotransmitter activity).
Living with POTS
By consistently paying attention to sodium and fluid intake, compression and exercise, as well as the behavioral changes and medications discussed above, many people with POTS can successfully attend hospital. school and get a job. However, symptoms can flare up without warning. Arranging formal accommodations, such as frequent snack breaks and flexible schedules, can help people thrive in an academic or professional setting.
Finally, it is crucial to recognize the emotional consequences that chronic illnesses can have, particularly when they strike young people in the prime of their lives. Seeking support from friends and family and building a care team that understands POTS are essential parts of a successful treatment plan.
Additional Resources
International dysautonomia is an organization that raises awareness, promotes research, and connects people living with POTS and other forms of dysautonomia.
POTS – Together we stand together: surfing the waves of dysautonomia (Jodi Epstein Rhum and Svetlana Blishteyn, independent publishing platform CreateSpace, 2011). This book offers practical advice on exercise, diet and accommodations.