POTS
Postural Orthostatic Tachycardia Syndrome
A syndrome typically occuring in young women, experienced as vague symptoms (light headed, palpitations, brain fog, etc) in standing position and relieved by sitting or lying
Several theories about physiology – low volume, inadequate vasoconstriction, heightened noradrenergic response
Underlying cause ?genetic ?deconditioning ?autoimmune
Commonly associated with hypermobilitiy, fibromyalgia, migraine, etc
Triggers – viral (including covid), pre-menstrual
Malmo POTS survey – score > 42 has high sensitivity and specificity for POTS
https://potsfoundation.org.au/wp-content/uploads/2025/06/MALMO-MAPS-one-page.pdf
Active Stand Test – HR/BP after 5min supine. Repeat after 3min stand, 5min stand up to 10min. Diagnostic if HR > 30 and BP drop < 20/10.
Investigations – ECG, Holter, Echo, ABPM, Bloods (FBC, ELFT, TFT, cortisol, BHCG, ferritin). MRI is postural headache
Management
Lifestyle- 3L fluid/day, Salt 10g/day, compression stockings full-leg (15-20mmHg) or abdominal binder, graded exercise (POTS-aware ex physiologist)
Drug treatment
Betablockers – propranolol 10mg BD -> 20mg BD
Ivabradine 2.5mg BD -> 5mg BD
Fludrocortisone 50mcg daily -> 100mcg. Monitor BP and hypokalaemia
Midodrine – can be used on demand. 2.5mg up to TDS. Onset 20min, lasts 3 hrs. Expensive
Pyridostigmine (mestinon) – promotes vasoconstriction
Useful website
POTS For Practitioners