POTS Definition, Assessment, and Naturopathic Treatment by Dr Carissa Doherty, ND

What is POTS?

Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous multifactorial disorder characterized by orthostatic tachycardia and intolerance, which can impair quality of life (1). POTS symptoms may be induced by physical deconditioning, immunological factors, hypovolemia, autonomic dysfunction, elevated sympathetic tone, and venous pooling (1).

Symptoms of POTS are as follows (2):

Cardiovascular symptoms:

• Lightheadedness (99%)
• Tachycardia (97%)
• Pre-syncope (94%)
• Shortness of breath (88%)
• Palpitations (87%)
• Chest pain (79%)
• Low blood pressure (71%)
• Syncope (36%)

Gastrointestinal symptoms:

• Nausea (90%)
• Stomach pain (83%)
• Bloating (79%)
• Constipation (71%)
• Diarrhea (69%)

Neurological symptoms (head and brain):

• Headache (94%)
• Difficulty concentrating (94%)
• Memory problems (87%)
• Tremulousness (78%)

Neurological symptoms (eyes and ears):

• Blurred vison (75%)
• Dry mouth (66%)
• Dry eyes (60%)

Neurological symptoms (extremities):

• Muscle pains (84%)
• Cold feet (94%)
• Muscle weakness (83%)
• Hand coldness (82%)
• Hand tingling (76%)
• Foot tingling (67%)
• Hand numbness (65%)
• Foot numbness (58%)

Skin symptoms:

• Skin flushing (69%)

Bladder symptoms:

• Frequent urination (68%) (2)

What is the pathophysiology of POTS?

Most patients with POTS have low cardiac stroke volume,which may cause the sinus tachycardia (3). There are three known subgroups of POTS which include increased sympathetic nervous system tone (i.e., hyper adrenergic POTS), partial peripheral sympathetic denervation leading to relative central hypovolemia (i.e., neuropathic POTS), and low blood volume (i.e., absolute hypovolemia) (3).

Hyper adrenergic symptoms can include tremulousness, anxiety, migraine, and angina-like chest pain (4). Neurological symptoms related to blood pooling include dizziness, lightheadedness, headaches, migraines, brain fog, fatigue, and sleep abnormalities. Sympathetic nervous system stimulation, which is gastrointestinal in nature include, gastroparesis (stomach paralysis), rapid gastric emptying, impaired motility, fecal loading, and nausea and vomiting (4).

Postural orthostatic tachycardia syndrome may have an immunological cause (4). Many patients describe a post-viral onset, and 15%–20% of patients with POTS report a history of an autoimmune disorder such as Hashimoto thyroiditis, rheumatoid arthritis or Sjögren syndrome (5).

How common is POTS?

Experts have estimated that up to 3 million Americans could be affected, and potentially 70 million worldwide (1). One study in China reported 6.8% of adolescents met clinical criteria for POTS (6). POTS is a common neurocardiovascular disease, representing approximately 32.2% of all corresponding syncope cases (1). POTS is one of the most common forms of autonomic dysfunction (1).

Clinical Definition of POTS

• A sustained HR increment of no fewer than 30 beats/minute within 10 minutes of standing or head-up tilt. For individuals who are 12 to 19 years old, the required HR increment is at least 40 beats/minute
• An absence of orthostatic hypotension (i.e., no sustained systolic blood pressure [BP] drop of 20 mmHg or more)
• Frequent symptoms of orthostatic intolerance during standing, with rapid improvement upon return to a supine position. Symptoms may include lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, and fatigue
• Duration of symptoms for at least three months (7).

How to assess for POTS

• A tilt table test, sometimes known as a passive head-­up tilt test (HUTT). This procedure is used to record both blood pressure and heart rate each minute while the patient is tilted on a table at varying levels.
• IV takes blood to measure adrenaline.
• Blood pressure cuff on both arms and electrical activity of the heart are taken (1,3)

Fix the POTS first in a case

Why is it important to treat POTS first in a case?

POTS has an impact on the circulatory system in both blood volume and inflammation. If a patient has POTS and any other condition, the POTS mechanically impacts the successful treatment of anything else. There would literally not be the capacity for the protocol to be delivered via the blood to the system that requires the support.

Why is POTS relevant now?

Recent reports indicate that 2% to 14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9% to 61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6 to 8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (5). “Post–acute sequelae of SARS-CoV-2 syndrome,” “post–coronavirus disease 2019 (COVID-19) syndrome,” “long-haul COVID,” or “long COVID” and are usually defined as symptoms that persist for more than four weeks from acute illness (8).

Some researchers argue that Long COVID is caused by fibrin amyloid micro-clots that block up capillaries and limit the passage of red blood cells, and hence oxygen exchange, which could be the mechanism for the majority of these Long COVID symptoms (9,10,11).

Non-Pharmacological Treatment for POTS

• Water 3 L/d
• Salt 5 mL/d (2 tsp/d)
• Waist-high compression garments (1,3,13)

Hypovolemia

When people with POTS stand up, it causes a rapid gravitational displacement of approximately 500 to 700 mL of central blood volume into the splanchnic and lower extremity vascular beds (14). This causes venous pooling and decreases the return of blood to the heart producing a thoracic blood volume drop of about 30% which will decrease stoke volume and cardiac output (14). The primary treatment for POTS is to attempt repletion of blood volume.

Oral Salt Rehydration Therapy

Oral salt and water has been recommended to reduce orthostatic intolerance symptoms. One study at 2000 mg salt found that oral rehydration solution (salt with water and glucose or ORS) is a convenient, safe, and effective therapy for short-term relief of orthostatic intolerance (14,15). Patients are encouraged to consume electrolyte beverages to increase osmotic pressure and keep the fluids in the intravascular space. The rationale is expansion of intravascular volume to compensate for intravascular hypovolemia and orthostatic pooling. Consensus-based guidelines have recommended, in addition to drinking 2 to 3 L of water daily, sodium chloride, 8 to 12 g/d (350 to 520 mmol/d sodium) (14,15)

There are 5 subtypes of POTS based on its pathophysiology: three are known and two are anecdotal.

Known

• Hypovolemic
• Hyper adrenergic
• Neuropathic

Anecdotal

• Immune-related (MCAS/Inflammation in the blood vessels) (12)
• Microcirculation (1,3,14,16,17,18)

Naturopathic Treatment Ideas:

• Low blood volume or hypovolemic is best treated by salt (1,3,14)
• Hyper adrenergic mechanisms for POTS have potential treatment strategies which include ways to metabolize adrenaline in the liver and ways to block adrenaline receptor activity. Nutrients for metabolizing adrenaline include inositol, B12, magnesium, and B vitamins (15). Potential mechanisms to impede adrenaline in the body include valarian and melatonin (15).
• Neurogenic supports such as B1, sulfate, B12, CoQ10, carnitine, alpha-lipoic acid, and B6 (19,20).
• Inflammation in the blood vessels can include mast cell activation. Possible treatment strategies include the use of zinc and quercetin for the zinc ionophore properties and the anti-inflammatory properties of quercetin including the anti-histamine property (12).
• Microcirculation support in POTS can include the following supports: herbs such as ginko, grapefruit seed extract, hawthorn, and micronutrient support such as carnitine, vitamin E, coenzyme Q10, vitamin C, and phosphatidycholine (16,17,18). Microcirculation support should include nitric oxide production (17).

Pharmaceutical interventions for POTS are helpful to alleviate symptoms but they address the downstream inflammation that occurs after the significant reaction to low blood volume. Salt as the primary treatment for POTS is under-used as a recommendation, often done verbally by the patients being told to just eat more salty foods but not given amounts of salt or what other electrolytes should be given.

Naturopathic interventions, along with salt, will work synergistically to help address the root cause of the POTS instead of just dealing with the inflammation and reactions that POTS makes.

Simple POTS testing to tell Patients

Ask patients to check their heart rate while reminding them that heart rate is beats per minute. Ask patients to check heart rate in three positions in the following order:

• Seated
• Lying down
• Standing

Adult heart rate should be in the range of normal which is 55 to 75 beats per minute (bpm). If there is an elevation in heart rate over 30 points when standing immediately or even after 10 minutes, then think about POTS as a diagnosis.

References:

1. Raj, S. R. (2021, Nov 25). Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting – Part 2. Autonomic Neuroscience: Basic and Clinical. 2021. Vol. 235 Pages 102836. DOI: 10.1016/j.autneu.2021.102836
2. B. H. Shaw, L. E. Stiles, K. Bourne, E. A. Green, C. A. Shibao, L. E. Okamoto, et al. The face of postural tachycardia syndrome – insights from a large cross-sectional online community-based survey. Journal of Internal Medicine 2019 Vol. 286 Issue 4 Pages 438-448. DOI: doi.org/10.1111/joim.12895.
3. Satish R. Raj, Artur Fedorowski and Robert S. Sheldon. Diagnosis and management of postural orthostatic tachycardia syndrome. CMAJ March 14, 2022 194 (10) E378-E385; DOI: 10.1503/cmaj.211373
4. A. D. Desai, B. C. Boursiquot, C. J. Moore, R. Gopinathannair, M. P. Waase, G. A. Rubin, et al. Autonomic dysfunction post-acute COVID-19 infection. HeartRhythm Case Rep 2022 Vol. 8 Issue 3 Pages 143-146.  DOI: 10.1016/j.hrcr.2021.11.019.
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11. M. Zuin, M. M. Engelen, S. Barco, A. C. Spyropoulos, T. Vanassche, B. J. Hunt, et al. Incidence of venous thromboembolic events in COVID-19 patients after hospital discharge: A systematic review and meta-analysis.Thrombosis Research 2022 Vol. 209 Pages 94-98. DOI: 10.1016/j.thromres.2021.11.029. DOI: 10.1016/j.autneu.2018.05.001
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