The Treatment of POTS
Postural Orthostatic Tachcardia Syndrome that May Lead to Syncope
General principles of treating syncope (fainting) are to determine how much risk the patient has for another syncopal episode, and to determine its cause. This is important, because one cannot simply go about life fainting in public and dangerous places.
Treating syncope also treats most POTS, but the quest is still to determine heart vs. unexplained events vs arrhythmia or abnormal rhythm, versus predictability of future events (See Chart below).
A slow heart rate, or bradycardia, can be treated by a pacemaker that prevents a slow flow. If the patient also has a low blood pressure, a pacemaker is less effective.
Finding the cause of the underlying disease may prevent recurrences.
Syncope only recurs in less than 50% of patients in the next 1-2 years. If the patient is low-risk, the problem may spontaneously resolve.
I think I passed out 40-50 times in my first year, and for about 12 years thereafter, it gradually slowed down to a screeching halt.
Treatment is based on risk.
A series of nonpharmacologic and pharmacologic interventions may alleviate symptoms:
Compression stockings and/or abdominal binder: 30-40mm Hg strength as knee-socks or thigh-highs.
High salt intake: some need salt tablets, especially during hot summer months.
Increase total body salt: fludrocortisone 0.1-0.3 mg/day increases blood volume by retaining salt.
Some can go ahead an eat as much salt as they can, and know what level their brain feels best at.
Photo by Josh Massey on Unsplash Adequate hydration: drink plenty of fluids
Increase blood pressure: I was on midodrine, an alpha-agonist that pushed blood pressure up, as the first-line treatment for chronic autonomic failure, and it is increases BP whether laying or standing. Most start at 2.5 mg every 4 hours, around the clock, to a maximum of 10-20 mg every 4 hours.
Cardiac pacemaker
Beta-blockers - may make bradycardia worse
Paroxetine - an SSRI shown to be effective in one clinical trial.
Desmopressin for nocturnal polyuria, or frequent urination overnight
Octreotide for post-meal decreases in blood pressure
Erythropoetin for those who are anemic
Pyridostigmine
The use of walking sticks
Frequent small meals to avoid gastric overfilling
Swimming to streatmline leg and abdominal muscles
Droxidopa, a norepinephrine precursor as an alpha/beta agonist that is FDA approved for neurogenic orthostatic hypotension. In one study, any benefit to blood pressure was lost after 8 weeks.
Correct any arrhythmias: bradycardia, bifasicular BBB, tackycardia and pacing considerations occur when there is an established relationship betwen syncope and bradycardia.
Evaluate structural heart disease or inheritable arrhythmia (as they are associated with 2-4 times increased risk of death).
To avoid recurrence, avoid triggers like hot sun.
With syncopal episodes, the ER staff should be trained to differentiate between high-risk syncope vs low-risk syncope, and to admit the patient to the hospital when needed and without delay.
References
Dr. David S. Cannom, below in #1, was the cardiologist who saved my life by treating my POTS when over 20 other doctors thought I was faking.
Olshansky B, Cannom D, Fedorowski A, Stewart J, Gibbons C, Sutton R, Shen WK, Muldowney J, Chung TH, Feigofsky S, Nayak H, Calkins H, Benditt DG. Postural Orthostatic Tachycardia Syndrome (POTS): A critical assessment. Prog Cardiovasc Dis. 2020 May-Jun;63(3):263-270. doi: 10.1016/j.pcad.2020.03.010. Epub 2020 Mar 25. PMID: 32222376; PMCID: PMC9012474.
Mar PL, Raj SR. Postural Orthostatic Tachycardia Syndrome: Mechanisms and New Therapies. Annu Rev Med. 2020 Jan 27;71:235-248. doi: 10.1146/annurev-med-041818-011630. Epub 2019 Aug 14. PMID: 31412221.
Raj SR, Bourne KM, Stiles LE, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Diedrich A, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Darbari A, Vernino S. Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Auton Neurosci. 2021 Nov;235:102836. doi: 10.1016/j.autneu.2021.102836. Epub 2021 Jun 30. PMID: 34246578; PMCID: PMC8455430.
Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med. 2019 Apr;285(4):352-366. doi: 10.1111/joim.12852. Epub 2018 Nov 23. PMID: 30372565.
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Orthostatic hypotension or dizziness on standing is a classic symptom of low blood pressure or dehydration.
Salt + water = hydration
Water follows salt.
Low salt consumption with any exposure to exertion or challenging heat/cold or stress etc reduces salt reserves.
Dehydration or hyponatremia is deadly.
The adrenals respond to this with all their adrenocortical hormones not just aldosterone.
Chronic dehydration results in chronic adrenocortical response. This changes the kidneys state of ease (releasing sodium) to dis-ease (retaining sodium). And results in adrenal fatigue or hyperplasia.
All sources of stores of sodium are raided to maintain hydration, for example: muscles, joint capsules, bones all lose salt and therefore loss of muscle mass, joint cushioning, bone density results.
The body thrives in a fully hydrated state. Think about a baby versus the elderly - the marked change is hydration. The body is self healing in a hydrated state. This is why hospitals use the ubiquitous saline drip. Rehydration is their biggest and best tool.
The red blood cells carry salt + water. Nothing to do with oxygen or carbon dioxide. They are vessels carrying and distributing salt water. The red light monitoring is checking for hydration not oxidation.
Dark RBCs are contracted and dehydrated.
Light RBCs are expanded and hydrated.
Monitoring the dark RBCs provides a measure for dehydration.
The lungs rehydrate RBCs by adding salt + water to the alveoli capillary beds as they pass through, the RBCs are spongelike and soak up the salt + water, expanding and hydrating. The saline drip adds salt water to RBCs through venous exposure.
The topic of dehydration is occulted with the medical malfeasant mis-direct to oxidation or oxidative stress.
Re- program yourself to rephrase oxidative stress to dehydration and the spell is broken.
I explain why oxygen is toxic and kills in my article titled:
We breathe air not oxygen
Be great if everyone understood why oxygen is not prescribed for breathlessness.
Instead it is primarily prescribed for the terminally ill.
Palliative care is not kind!
https://open.substack.com/pub/jane333/p/we-breath-air-not-oxygen?utm_campaign=post&utm_medium=web