Download Postural Orthostatic Tachycardia Syndrome (POTS)

Postural Orthostatic Tachycardia Syndrome (POTS)
A Practice Philosophy
Postural orthostatic tachycardia syndrome (POTS) is a medical condition that is relatively new in
terms of a description and understanding. As a result, we do not have a lot of clinical experience
or medical evidence concerning its diagnosis, treatment, and prognosis. In fact, many patients
with POTS are discouraged to find that their primary care doctor has not heard of the condition.
Patients frequently undergo a lot of testing with very little to show for it. This statement
represents my personal perspective on POTS gathered from several years of patient care and my
understanding of the medical research.
Here is how I understand postural orthostatic tachycardia syndrome. Most people in the world
are going to have at least one fainting spell. The fainting spell may occur in the typical situation
of someone is standing at the back of a hot, crowded room. They feel the episode coming on and
they fall to the floor. Typically, there is a drop in their blood pressure or fall in their heart rate,
or both. I consider POTS to be the body’s attempt to respond to that type of situation in a
different manner. When the blood pressure starts to fall, the patient feels like they might faint,
and the heart rate increases dramatically in order to keep the circulation of the blood at a high
enough level that fainting does not occur. (This is how it got its name: racing heart beats
(tachycardia) when a person stands up (orthostatic). That is the good part about POTS. Fainting
spells usually represent just a small part of their collection of symptoms. The bad part about this
reaction of fast heart rates in the upright position is that the person who has this problem often
has prolonged periods of time with a racing heart rate during minimal activities. As a result, the
heart races so much that it is like walking on a fast paced treadmill. After a while, chronic
fatigue may set in. With that come symptoms of difficulty with concentration, brain fog,
palpitations, nausea, indigestion, cold hands and feet, and a variety of other symptoms.
In my experience at least 50% of people who have POTS are able to identify when the problem
began. Of those, a substantial number are able to identify the event that triggered their problem.
Often, it is something like surgery, or an injury that calls for bed rest, some kind of illness or a
very stressful situation (this could be emotional, physical or psychological stress).
One theory about POTS is that it represents an exaggerated form of deconditioning. Think about
this, who has the worst postural orthostatic tachycardia? The answer is the person returning from
the space station after several weeks or months at zero gravity. The people selected to be
astronauts are among the most healthy, physically fit people in America. And yet, have you
ever wondered why that space capsule would land and the astronaut did not fling the door open
and wave to the television cameras? The answer is that zero gravity for several weeks created
such severe POTS that they would be lucky to pick their head up, much less stand and wave.
Because of zero gravity for weeks, they develop extreme orthostatic intolerance (inability to be
upright). They need to embark on a program of physical therapy and reconditioning in order to
regain their previous status.
So, this theory of exaggerated deconditioning goes like this: the person with POTS will have an
illness, surgery, injury or some other problem that causes them to be at significantly reduced
activity levels, if not bed rest, for just a few days. Perhaps because of some genetic
predisposition, they develop this change of deconditioning in which their heart races when they
are upright and they tire excessively with minimal activity. The solution to this is just the same
as it is for an astronaut returning from an extended time on the space station: reconditioning
exercise, and rehabilitation.
If you have read this far, you probably also have enough tolerance for bad things that can happen
to people that you know this too: life is not fair. Some people develop medical problems that
would not affect other people. POTS causes extreme exercise intolerance and the
recommendation for the person is that they start to exercise! It is my philosophy that exercise in
the only thing that is really helpful to speed up the time course in which patients recover from
POTS. Medications can be used in the meantime to help control symptoms, for those patients
who need them.
The type of exercise that POTS patients should do is based on what they are able to tolerate.
Swimming is an ideal exercise because the patient can be horizontal as they swim through the
water and they can get good exercise that way. Also, if the patient is standing up in the water,
the water presses against the legs and their trunk and helps return blood to the heart, reducing the
effects of gravity.
For a variety of reasons, some people just don’t take to swimming like a duck to water. If they
don’t know how to swim, don’t feel comfortable about how they look in a bathing suit or hate
the smell of chlorine, they need some other type of exercise. One good exercise is to use a
recumbent bicycle. Here the person gets the advantage of exercise, but they are leaning way
back so there is much less gravitational stress.
Another form of exercise is controversial because the medical research is split on its
effectiveness. That exercise is tilt training. If you have had a tilt table test, you remember you
were asked to be almost completely upright, but not move your arms and legs to speed up the
return of blood back to your heart. That test then focuses on the small blood vessels that are the
ultimate step in terms of blood pressure control. With tilt training you duplicate that by leaning
back against the wall, keeping your feet about 18 inches from the wall. Some patients with
POTS can do this very easily, and others can only tolerate one or two minutes before they need
to move about.
With all of these exercises, the trick is to find out what works best for you and do it to tolerance.
That is, don’t try to push too hard but try to extend your effort on a regular basis.
I think there is very good news for patients with POTS. Nearly all of them are people who are
young and completely healthy at the time their problem began. Nearly everybody in this
category will recover completely from POTS. Exercise helps speed up the time to recovery and
medications can provide relief of or improvement in symptoms in the meantime.
Patients with POTS should also be reassured that we may not be able to explain all of the details
about why POTS occurs but we do know this important fact: these symptoms of POTS are much
more annoying than anything else. They are not the sign of a serious medical problem such as
cancer, heart failure, warning of stroke, or the sign of some serious endocrine problem. Many
patients with POTS get tested for these things by well meaning physicians. Unfortunately, this
plants the seed that this condition is serious and that concern acts as a magnifying glass to make
everything seem worse. Consider the analogy to a tension headache. Sometimes we can identify
why it happens and sometimes it is related to stress. The patient can feel pretty uncomfortable, if
not downright miserable, but it is not dangerous and there is no need for the patient to be
concerned about their long term health.
There are certain experts on POTS who will try to identify each of the symptoms that might be
present and then see if they can find a specific medicine for each one of those symptoms.
Sometimes that means 3-5 medicines. These medicines also have a pretty good likelihood of
causing side effects so these doctors are prepared to provide additional medications to counteract
these side effects. Although several of these doctors are world famous for their treatment of
POTS, my philosophy is the exact opposite. It is based on my understanding that this is a
temporary condition that affects people who are completely normal and healthy. It may be
triggered by surgery, an injury, bed rest or a stressful situation and then represents exaggerated
deconditioning. Patients should do remarkably well and recover. Typically, this recovery takes
months and sometimes a few years.
The issue of POTS as a complication for a patient with multiple other medical problems reminds
me of a question I fell for during my first year in practice. Years ago, we used to do a heart
catheterization by making a cut in the arm and using the artery by the elbow. Some patients
found this very frightening, so we had to take pains to reassure them. One person asked me if he
would be able to play the piano after this procedure. Of course, I reassured him. With a
twinkle in his eye, he said “great because I can’t play at all now.” For the patient who has POTS
as a complication of other multiple medical problems, I am also confident that POTS will be a
short-lived aggravating medical issue but it also will resolve. Unfortunately, these people don’t
return to the prime of health, but to their baseline state that they experienced prior to the
development of POTS.
There are several websites that patients turn to for information about POTS and there are printed
materials available from national centers such as the Mayo Clinic and Vanderbilt University.
Please be reminded that this material represents my own practice philosophy. It is based on my
experience with what seems to work. I have lots of satisfied, happy patients who have been able
to work through and outgrow their symptoms of POTS. I hope you are one of those as well.
Felix J. Rogers, D.O.
March 21, 2009