Postural Tachycardia Syndrome: Beyond Orthostatic Intolerance

Abstract

Postural tachycardia syndrome (POTS) is a form of chronic orthostatic intolerance for which the hallmark physiological trait is an excessive increase in heart rate with assumption of upright posture. The orthostatic tachycardia occurs in the absence of orthostatic hypotension and is associated with a >6-month history of symptoms that are relieved by recumbence. The heart rate abnormality and orthostatic symptoms should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia. POTS is a "final common pathway" for a number of overlapping pathophysiologies, including an autonomic neuropathy in the lower body, hypovolemia, elevated sympathetic tone, mast cell activation, deconditioning, and autoantibodies. Not only may patients be affected by more than one of these pathophysiologies but also the phenotype of POTS has similarities to a number of other disorders, e.g., chronic fatigue syndrome, Ehlers-Danlos syndrome, vasovagal syncope, and inappropriate sinus tachycardia. POTS can be treated with a combination of non-pharmacological approaches, a structured exercise training program, and often some pharmacological support.

Figure 1

Many patients think about the different subgroups of POTS as distinct and mutually exclusive groups (Panel A). While the subgroups are useful pathophysiological concepts, in clinical practice, the subtype labels are often used to describe individual test findings, and the same patient can fit into more than 1 overlapping subtype (Panel B).

Figure 1

Many patients think about the different subgroups of POTS as distinct and mutually exclusive groups (Panel A). While the subgroups are useful pathophysiological concepts, in clinical practice, the subtype labels are often used to describe individual test findings, and the same patient can fit into more than 1 overlapping subtype (Panel B).