GP Guide: PoTS on a Page

What is PoTS?

PoTS stands for postural tachycardia syndrome. First characterized and defined in 1993.

It is a common, debilitating condition.

DESCRIPTION – Abnormal response by the autonomic nervous system to upright posture. In some, the mechanism is lack of vasoconstriction on standing causing pooling of blood in abdomen and limbs, reduced venous return to heart, compensatory tachycardia and altered cerebral circulation.

Most common in females age 15-50 

DISABILITY – equivalent to disability found in heart failure + COPD 

ASSOCIATED WITH 

• Hypermobility
• after viral infections eg COVID 19, Glandular Fever
• ME/CFS
• Mast Cell Acitivation Syndrome
• autoimmune conditions  
• growth/puberty in children

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When to suspect PoTS

SUSPECT PoTS in   

• medically unexplained symptoms 
• ME/CFS 
• hypermobile patients  
• post-COVID patients

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Symptoms

3 commonest symptoms are 

• lightheadedness (presyncope) 
• fatigue 
• palpitations  

Other symptoms include 

• fainting 
• nausea, bloating, abdominal pain 
• cognitive dysfunction – ‘brain fog’ 
• poor sleep 
• exercise intolerance  
• shakiness, sweating 
• postural headaches and migraines 

SIGNS   *occur on standing/prolonged sitting* 

• tachycardia  
• acrocyanosis – red/purple puffy hands and feet (50% of patients)

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How to diagnose PoTS

DIAGNOSTIC CRITERIA – Sustained increase in heart rate of 30 beats per minute (40bpm in teenagers) from lying to standing associated with symptoms of PoTS

STAND TEST – rest supine and record HR and BP. Then stand in a safe place and record BP and HR every 2 minutes for 10 minutes

INVESTIGATIONS – ECG. Exclude anaemia, hyperthyroidism, postural hypotension, phaeochromocytoma  

MISDIAGNOSIS – Mean time to diagnosis is 7 years.

50% of patients receive a psychiatric misdiagnosis e.g. anxiety, depression, hypochondriasis. Other misdiagnoses – ME/CFS.

SPECIALISTS WITH AN INTEREST IN PoTS – There is a list of clinics on our website: https://www.potsuk.org/clinics/

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How to manage PoTS 

AVOID TRIGGERS – heat, large meals, alcohol, drugs that lower BP 

FLUIDS – at least 2-3 litres a day in adults 

SALT – Adults: +6g/day (unless contraindicated) 

EXERCISE – initially supine, graduated regimen, can take several months to improve symptoms. Take caution if severe post-exertional malaise. 

POSTURAL MANOEUVRES to avoid fainting – avoid prolonged standing, elevate legs, tense buttocks + thighs, fold arms, tiptoe 

COMPRESSION – Class 2 compression tights or compression leggings, waist high

DRUGS -include β blockers, calcium channel blockers, ivabradine, midodrine, fludrocortisone, clonidine, SSRI, desmopressin, pyridostigmine, octreotide 

CBT – to help adjust to chronic illness 

IV FLUIDS – in an emergency only. Further info here 

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