OSANG Neurosurgery & Neurology
1599-5453

OSANG SPECIALTY CENTER

Autonomic Clinic

POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME

If your heart beats wildly every time you stand up,Could it be postural orthostatic tachycardia syndrome (POTS)?

Postural tachycardia syndrome (POTS) is an autonomic dysfunction in which the heart rate increases abnormally when standing up, causing dizziness, palpitations, brain fog, and chronic fatigue. It is characterized by an increase in heart rate of more than 30 beats per minute even though blood pressure does not drop significantly.

Within 10 minutes after standing upheart rate changes
72
112

Increased by more than 30 times per minute for adults

DEFINITION

What is orthostatic tachycardia syndrome (POTS)?

Postural orthostatic tachycardia syndrome, POTS) within 10 minutes after standing up Heart rate increases more than 30 beats per minute(40 or more times for teenagers aged 12 to 19) Not accompanied by orthostatic hypotension It is a chronic autonomic dysfunction. According to the 2015 American Heart Rhythm Society expert consensus statement, POTS is diagnosed when the heart rate increases by more than 30 beats per minute within 10 minutes of standing up for adults, or when the absolute heart rate exceeds 120 beats per minute and systolic blood pressure does not fall by more than 20 mmHg. POTS is not a single disease, but involves multiple pathophysiological mechanisms, including neuropathic, hyperadrenergic, hypovolemic, autoimmune, and post-infectious. syndromeIn one patient, multiple mechanisms may overlap. It is estimated that approximately 1 to 3 million people in the United States have POTS, and approximately 80% of patients are women of childbearing age between the ages of 15 and 50, with a female-to-male ratio of approximately 5:1.

POTS is an autonomic dysfunction in which the heart rate increases more than 30 beats per minute when standing up, although blood pressure does not drop.

SYMPTOMS

What symptoms do you experience?

Palpitations and dizziness when standing up are the key symptoms, and dysregulation of the overall autonomic nervous system, such as brain fog, chronic fatigue, digestive symptoms, and sweating abnormalities, also appear. It is characterized by relief when lying down and worsening when standing up.

  1. 01

    Palpitations and excessive tachycardia when standing up

    A key finding is that the heart rate rises rapidly when standing up. The most common symptom patients complain of is palpitation, which may also be accompanied by chest discomfort or chest pain. In some cases, systolic blood pressure may temporarily increase when standing up.

  2. 02

    Dizziness, pre-syncope symptoms, brain fog

    Dizziness and headache are the most common symptoms and presyncope occurs. True syncope is relatively rare, reported in only about 30% of patients. Decrease in cognitive function (decreased concentration, memory, and thinking speed) expressed as brain fog is very common and worsens in a standing position and normalizes when lying down.

  3. 03

    Chronic fatigue and exercise intolerance

    Chronic fatigue occurs in approximately 48-77% of patients. Even light physical activity causes extreme fatigue and worsens symptoms, resulting in exercise intolerance, which is accompanied by sleep disturbance and creates a vicious cycle that further worsens fatigue.

  4. 04

    digestive symptoms

    Nausea, abdominal pain, abdominal distension, and early satiety are common, and gastrointestinal motility disorders include constipation or diarrhea. In a Mayo Clinic study, about 39% of patients complained of nausea.

  5. 05

    Abnormal sweating, discoloration of limbs, etc.

    Excessive sweating or anhidrosis, purplish discoloration of the extremities (acrosyanosis), blurred vision, tremors, shortness of breath, and facial flushing may occur. Symptoms are relieved when lying down and worsen when standing, and become more severe due to the menstrual cycle, temperature, dehydration, and standing for long periods of time.

CAUSES

Why does it happen?

POTS is a syndrome that does not have a single cause but involves multiple pathophysiological mechanisms. It is divided into subtypes depending on which mechanism is dominant, and the treatment direction also varies.

  1. 01

    POTS (Neuropathic)

    Damage to sympathetic nerve fibers in the lower extremities and visceral regions results in insufficient vasoconstriction upon standing, blood pooling in the lower extremities, and an excessive increase in heart rate to compensate. Approximately 50% of patients present with small fiber neuropathy, and skin biopsies reveal decreased intraepidermal nerve fiber density.

  2. 02

    Hyperadrenergic POTS (Hyperadrenergic)

    This is a type in which excessive norepinephrine is secreted when standing, and the level of norepinephrine in the blood rises to over 600 pg/mL while standing. It is observed in approximately 30-60% of all patients and is accompanied by tremor, anxiety, and excessive sweating, and blood pressure may actually rise when standing.

  3. 03

    POTS (Hypovolemic)

    This is a type in which the amount of circulating blood in the body is absolutely insufficient, and the plasma volume is reduced by about 13% compared to the control group. Heart rate increases to compensate for decreased venous return, and dysregulation of the renin-angiotensin-aldosterone system is thought to be involved.

  4. 04

    Autoimmune POTS (Autoimmune)

    It occurs when autoantibodies attack autonomic nervous system receptors. In approximately 25% of patients, antinuclear antibodies (ANA) are positive and autoantibodies against adrenaline, muscarinic, and autonomic ganglionic acetylcholine receptors are detected. It is frequently accompanied by Sjögren's syndrome and Hashimoto's thyroiditis.

  5. 05

    Post-infectious (POTS)

    This type occurs within a few weeks to several months after a viral or bacterial infection. There have been reports of mononucleosis (EBV) and Lyme disease in the past, but the number has increased rapidly since the COVID-19 pandemic. Approximately 2-14% of COVID-19 patients develop autonomic dysfunction after infection, and many meet the criteria for POTS. A molecular mimicry mechanism in which the immune response attacks autonomic nerve fibers is likely.

DIAGNOSIS

How is it diagnosed?

The diagnosis of POTS is based on a combination of clinical symptoms, hemodynamic response upon standing, and exclusion of other diseases. The standard test is the standing incline table test (tilt test), and the subtype is differentiated by measuring heart rate variability (HRV) and blood catecholamines.

Standard diagnostic tests are Standing tilt table test (tilt test)It is. The patient is laid down on the examination table and rested for 5 to 10 minutes, then tilted to an angle of 60 to 70 degrees. POTS is diagnosed if the heart rate increases by more than 30 beats per minute (more than 40 beats per minute for those aged 12 to 19) within 10 minutes after standing up, or if the absolute heart rate exceeds 120 beats and the systolic blood pressure does not fall by more than 20 mmHg. In outpatient clinics, blood pressure and heart rate are measured at 1, 3, 5, and 10 minutes after standing up. active standing testis implemented for screening purposes. To evaluate the sympathetic-parasympathetic balance of the autonomic nervous system Heart rate variability (HRV) analysisis used to confirm increased sympathetic nerve activity and decreased parasympathetic nerve function at rest in POTS patients and to monitor treatment effects. Standing position for subtype differentiation Measurement of blood catecholamines (norepinephrine)(Above 600 pg/mL suggests hyperadrenergic function). If autoimmunity is suspected, antinuclear antibody, anti-SSA/SSB, and autonomic ganglion acetylcholine receptor antibody tests are added. In addition, thyroid function tests, 24-hour urine sodium excretion, plasma volume measurement, quantitative sweat axon reflex test (QSART), and skin biopsy are performed, and it is essential to differentiate similar diseases such as pheochromocytoma, inappropriate sinus tachycardia, and hyperthyroidism. At the Osang Neurosurgery Autonomic Nerve Clinic, we identify the presence and subtype of POTS using a battery of precise autonomic nerve tests such as standing tilt, HRV, and qEEG.

  1. 01standard diagnosis

    Standing incline table test (tilt test)

    After resting for 5 to 10 minutes, tilt to 60 to 70 degrees, and if the heart rate increases more than 30 beats per minute (40 beats per minute in teenagers) within 10 minutes and there is no orthostatic hypotension, it is a standard test to diagnose POTS.

  2. 02autonomic function

    Heart rate variability (HRV) analysis

    Objectively assess sympathetic-parasympathetic balance. It is used to identify overactivity of sympathetic nerves and decreased parasympathetic function at rest in POTS patients and to monitor treatment effects.

  3. 03Subtype differentiation

    Blood catecholamine measurement and autoantibody test

    A norepinephrine level of 600 pg/mL or more when standing suggests hyperadrenergic function. If autoimmunity is suspected, antinuclear antibodies and autonomic ganglion acetylcholine receptor antibodies are added to determine the subtype.

TREATMENT

How do I treat and manage it?

Non-drug treatments such as moisture and salt supplementation, compression clothing, and exercise rehabilitation are basic, and drug, immune, and neuromodulation treatments are combined depending on the subtype and symptoms. A combination of methods is most effective.

  1. 01

    Water and salt supplementation

    It is the basis of treatment for all patients. Consuming 2 to 3 liters of water and 6 to 10 g of salt a day increases plasma volume and relieves orthostatic symptoms. However, if you have heart or kidney disease, you must consult your doctor.

  2. 02

    Compression clothing and posture management

    Compression stockings rated 30 to 40 mmHg that extend to the waist are effective, and compression garments that extend to the abdomen are more effective in reducing visceral blood retention. Sleep with the head of your bed raised 10 to 15 degrees, avoid sudden changes in posture, and activate lower extremity muscle pumps by crossing your legs and tiptoing when standing.

  3. 03

    Exercise rehabilitation (Dallas protocol)

    Exercise is the non-pharmacological intervention with the strongest evidence base. The progressive program developed by Fu·Levine consists of three stages: lying down exercise (1 to 2 months) → progressive standing exercise (2 to 3 months) → maintenance phase (after 3 months). At the completion of 3 months, approximately 71% of patients improve below diagnostic criteria, with left ventricular volume increasing by approximately 8% and plasma volume increasing by approximately 6%. Even if there is temporary worsening for the first 1-2 weeks, it will improve if you endure it.

  4. 04

    medication

    Choose based on subtype and main symptoms. Control heart rate with low-dose beta-blockers (propranolol 10-20 mg), improve vasoconstriction and venous return with midodrine (2.5-10 mg), reduce heart rate with ivabradine (2.5-7.5 mg), increase plasma volume with fludrocortisone (0.1-0.2 mg/day), and enhance autonomic ganglia transmission with pyridostigmine (30-60 mg). It is difficult to control all symptoms with a single drug, so combination treatment is effective.

  5. 05

    Immune/neuromodulation treatment

    If autoimmunity is confirmed, intravenous immunoglobulin (IVIG) or immunomodulatory treatment is attempted. If sympathetic nerve hyperactivation is significant, stellate ganglion blockade is used to temporarily suppress sympathetic nerve output, and transcranial magnetic stimulation (TMS) is used to help restore the function of the autonomic control center.

AUTONOMIC PROGRAM 01

Neural Reset Protocol

This is a treatment protocol aimed at stabilizing the overly elevated sympathetic nervous system and restoring the function of the parasympathetic nervous system (vagus nerve).

Learn more

AUTONOMIC PROGRAM 02

NPT Program

This is Osang Neurosurgery’s non-surgical physical therapy program that directly stimulates the autonomic and peripheral nerve pathways.

Learn more

FAQ

Frequently Asked Questions

We have summarized the most frequently asked questions from patients regarding orthostatic tachycardia syndrome.

Q1What is postural orthostatic tachycardia syndrome (POTS)?

It is an autonomic nervous system disease in which the heart rate increases abnormally when standing up, causing dizziness, palpitations, and fatigue. Blood pressure does not drop significantly, but the heart rate rises to more than 30 beats per minute. An accurate diagnosis is important because it is a dysregulation of the autonomic nervous system that is different from anemia or heart disease.

Q2What causes POTS?

There is more than one cause. There are neuropathic types in which lower extremity blood vessels contract poorly, hyperadrenergic types in which stress hormones are excessively secreted, and hypovolemic types in which blood volume in the body is insufficient. Cases that occur after viral infection or involve autoimmune mechanisms have also been reported. Since treatment varies depending on the cause, the subtype must be identified through detailed examination.

Q3Why does it happen so often in young women?

Approximately 80% of patients are women aged 15 to 50 years. This is believed to be because estrogen affects vascular tone and autonomic nervous responses. Women tend to have relatively weaker lower extremity muscle pumps and less blood volume in their bodies, which puts them at a disadvantage in blood flow distribution when standing. Symptoms fluctuate depending on the menstrual cycle, so periodic observation is helpful.

Q4Can POTS occur after coronavirus infection?

Yes, many cases of POTS occurring after COVID-19 infection have been reported worldwide. If severe fatigue, palpitations, and dizziness persist even after recovery, POTS may be suspected. It is presumed that the virus directly damages the autonomic nervous system or that the immune response affects the autonomic nervous system. If you are having a hard time with your daily life due to the aftereffects of the coronavirus, we recommend an autonomic nerve test.

Q5What tests are used to diagnose POTS?

Standing incline table examination (tilt test) is the standard diagnostic method. POTS is diagnosed if the heart rate rises more than 30 beats per minute within 10 minutes of lying down at an angle of 60 to 70 degrees and there is no orthostatic hypotension. Heart rate variability (HRV) analysis, blood catecholamine measurement, and autonomic function tests are added to differentiate subtypes. At Osang Neurosurgery, we perform these detailed tests together.

Q6How is POTS treated?

Non-drug treatments such as exercise rehabilitation, fluid and salt supplementation, and compression stockings are basic. There is a study that showed that if a progressive exercise program (Dallas protocol) was continued for more than 3 months, approximately 71% of patients improved below the diagnostic criteria. Medications such as low-dose beta blockers, midodrine, ivabradine, and fludrocortisone are prescribed depending on symptoms. Combining multiple methods is effective, so we recommend that you make a customized plan with a specialist.

CONSULT

Postural Tachycardia Syndrome (POTS)Do you have any doubts?

If you have recurring palpitations, dizziness, or brain fog when standing up, check with a detailed standing tilt and HRV test at the Gangnam Osang Neurosurgery Autonomic Nerve Clinic.

Start with a detailed autonomic nerve testView Dysautonomia Test