Features May 2014 Issue

Putting Together the Pieces To Help Solve the POTS Puzzle

While its impact on your blood pressure and overall health can be overwhelming, there are answers for those riddled by this form of dysautonomia.

How could a perfectly healthy, active person suddenly become bedridden, unable to even stand for a few minutes without being overwhelmed with dizziness and complete exhaustion? This mysterious scenario has become a reality for more than 500,000 people in the United States today. Known as POTS, short for postural orthostatic tachycardia syndrome, this form of dysautonomia primarily affects women—and those affected often believe their lives will never be the same.

Treating POTS is a puzzling challenge because it is actually a collection of diseases that have many different causes.

While POTS is a puzzling syndrome, the autonomic disorder is definable by its predominant hallmark of an overactive heart rate in response to exercise or common daily activity. Yet, just as quickly as the condition can take over, the syndrome and its symptoms can be improved in the vast majority of patients, according to Cleveland Clinic cardiologist and Medical Director of the Syncope Center Fredrick Jaeger, DO.

“POTS, or dysautonomia, is not a specific disease; rather it’s a collection of diseases and symptoms with many different causes,” says Dr. Jaeger. “It’s truly an enigma because we don’t understand the precise underlying pathophysiology as to its cause. Because of this, we don’t have definite ways of treating POTS, but we do have a good ability to diagnose it and determine what may be impacting the patient’s autonomic nervous system.”

POTS and your body’s intranet
To understand the power of POTS over the body, think of how a computer’s internal network becomes incapacitated when attacked by viruses. Similarly when a virus or injury harms the body’s autonomic nervous system, its overall intranet of communication is scrambled, causing the chronic symptoms of POTS.

Defined as the presence of orthostatic intolerance accompanied by increased heart rate, POTS causes cardiac symptoms, including lightheadedness, chest discomfort, shortness of breath, and fainting (syncope). The syndrome can also be responsible for non-cardiac symptoms such as headache, nausea, sleep difficulties and cognitive impairment.

“There are several different varieties of disorders that can present in POTS, including hypovolemia, or an abnormal decrease in blood volume that results from blood pooling in the abdomen and legs,” he explains. “Patients can also be over-sensitive to their own adrenaline, or we can find that they have a neurological diagnosis.

“It’s not clear why women are more predisposed to POTS—it may be environmental factors or genetics,” says Dr. Jaeger. “Our approach is to dig to the underlying abnormalities and then target those with therapies.”

Tilting for answers
As the center to pioneer accurate diagnosis of dysautonomia and POTS, Cleveland Clinic offers a comprehensive panel of cardiovascular and neurological tests to assess the full spectrum of autonomic disorders. Central to initiating proper care of dysautonomia is the cardiovascular autonomic test with tilt, or tilt table test. The tilt table test records a patient’s blood pressure and heart rate on a minute-by-minute basis while the table is tilted in a head-up position at different levels.

“The results of the tilt test help us determine what may be causing symptoms of lightheadedness or syncope,” says Dr. Jaeger. “While we also test for other possible underlying cardiovascular problems, fortunately we rarely find them because POTS patients are typically young and otherwise healthy with normal hearts.”

Although cognitive impairment is usually moderate in patients with dysautonomia, the syndrome can cause severe impairment. In these patients, it’s important they undergo comprehensive evaluation to look for any structural neurologic disease, in addition to treatment for increased blood pressure and heart rate.

Action for relief
Research has shown that one component behind POTS is acute deconditioning. However, a study published in Hypertension: Journal of the American Heart Association found that exercise training made patients feel better without using the beta-blocker medication commonly given to lower the heart rate upon exertion.

“Lifestyle changes, particularly participating in an exercise program, have been shown to be very helpful for POTS patients,” explains Dr. Jaeger. “Our cardiac rehabilitation program starts with non-gravitational exercises, including using a recumbent cross trainer machine, recumbent bikes and aqua therapy. By increasing their cardiovascular conditioning we also reduce the pooling of blood in the legs.”

Additional non-pharmacologic treatments include being well hydrated by drinking eight to 10 cups of water or electrolytes daily and increasing sodium intake to five to seven grams each day. Wearing compression stockings also helps minimize blood pooling in the legs while decreasing overall symptoms.

While the majority of POTS patients find relief over time through exercise and lifestyle changes, medication may be required to make a difference. Beta-blockers, including low-dose propranolol (Inderal®), may be helpful in controlling tachycardia. For patients with blood vessel failure, the drug midodrine (Proamatine®) may be prescribed. And, while POTS patients may not be depressed, antidepressants such as a selective serotonin reuptake inhibitor may regulate adrenaline input to the body and improve blood pressure, explains Dr. Jaeger.

“While there are many medications that we commonly prescribe for POTS, our program tends to tailor medications based on individual status, abnormalities and demonstrated dysfunction,” he says. “Paramount in all of these is a concomitant exercise or reconditioning program.”

Comments (2)

Could the syncope response provide an evolutionary benefit to the species as a whole by increasing the probability of death of the individual? If the individual doesn't recognize any benefit to the species the brain invokes syncope so that the individual doesn't compete with its other members for resources. Females have a stronger commitment to other members so they have a higher probability.

Posted by: marlowg | December 7, 2016 3:23 AM    Report this comment

Could the syncope response provide an evolutionary benefit to the species as a whole by increasing the probability of death of the individual? If the individual doesn't recognize any benefit to the species the brain invokes syncope so that the individual doesn't compete with other members for resources. Females have a strong commitment to other members so they have a higher probability.

Posted by: marlowg | December 7, 2016 3:19 AM    Report this comment

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