What is POTS?

POTS is a type of dysautonomia that is characterized by an increase in heart rate on standing and symptoms of orthostatic intolerance (OI). The heart rate changes that define POTS are a 30 beat per minute increase in adults, and a 40 beat increase for adolescents. When a healthy person stands his/her heart rate will increase by 10 -15 beats per minute until the body adjusts to standing; it will then go back to a ‘normal’ rate (about 72 bpm). In a person with POTS this doesn’t happen.  The heart rate goes uncomfortably high (often over 140 bpm) and may continue to rise even higher if the person continues to stand.

POTS is a group of symptoms that frequently occur together and suggests a dysfunction of the Autonomic Nervous System (ANS). With no conscious thought on your part, your ANS guides your body through all the changes necessary to get through the day successfully. The autonomic nervous system functions with exacting precision. There are many points in the ANS that a problem can arise.

When we stand the veins in our legs and our abdomen need to constrict in order to compensate for gravity; the force of gravity causes a large amount of blood (approximately 500 -1000cc) to move out of our upper body and down to our abdominal circulation and legs. Within seconds, in a healthy person, the blood vessels tighten and send that blood back up to the heart so that it can be pumped to the brain and we can continue to think clearly and remain conscious. For various reasons, a person with POTS has a dysfunction in this constriction and so an inadequate amount of blood returns to the heart. In an attempt to compensate for this the heart beats much more quickly, trying over and over to get more blood to the brain. Without adequate blood flow to the brain, there comes headache, lightheadedness, dizziness, inability to focus, visual changes and for some, syncope (fainting) or pre-syncope, all classic symptoms of OI. For reasons that remain unclear, most people with POTS also suffer from hypovolemia (low blood volume), which makes this problem worse.

Our bodies work, at all costs, to keep us conscious and safe. When the brain senses that it is not getting enough blood there is an immediate outpouring of catecholamines (epinephrine (also called adrenaline) from the adrenal glands and norepinephrine from nerves) that would ordinarily help to keep blood flowing to the brain. Epinephrine and norepinephrine increase heart rate, constrict blood vessels, dilate pupils, cut blood flow to the gastrointestinal (GI) system; they  put us into the ‘fight or flight’ mode so that we can survive. This should only happen when our bodies are threatened but because a person with POTS is stressed every time she/he moves or stands, there is a constant outpouring of epinephrine and norepinephrine. It is for this reason that POTS is so often misdiagnosed as anxiety.

Symptoms often associated with POTS that are not necessarily related to position include, but are not limited to; unrelenting fatigue, headache, lightheadedness, dizziness, brain fog, nausea, diarrhea, constipation, bloating, chest pain, shortness of breath, burning in hands and/or feet, tremulousness, night sweats, insomnia and thermoregulatory issues; for some these symptoms are relieved by lying down, for many they are not. It is thought that these disturbances result from an imbalance between the sympathetic and parasympathetic nervous systems but the root causes of this imbalance are not understood.

With so many different systems being affected, and symptoms that mimic so many other disorders, patients are frequently referred from one specialist to another in an unsuccessful attempt to treat each symptom individually. Symptoms continue and patients can become more and more debilitated. A person with POTS feels as though it takes three times as much energy to accomplish any given activity compared to a person not affected with POTS. POTS does affect men but women are more often affected, the ratio is 5:1.

Research is only beginning to unveil the many causes and complexities of POTS. Several syndromes are known to be associated with POTS though underlying causes remain unclear. It is speculated that these causes/associations include, but are not limited to; viral illness, autoimmune disease, Lyme disease, Chronic Fatigue Syndrome, Mitochondrial dysfunction, Mast Cell Disorder, adrenal disorders, alterations in Angiotensin II, baroreceptor hypersensitivity and Joint Hypermobility Syndrome. At this time the goal of treatment is based on symptomatic relief and remains a process of trial and error. For some, treatment and life style modifications have a significant impact for others the benefit is marginal.

It is clear that this is a very complicated disorder; research and education are greatly needed.

Our bodies work, at all costs, to keep us conscious and safe… they put us into the ‘fight or flight’ mode so that we can survive.

This should only happen when our bodies are threatened but because a person with POTS is stressed every time she/he moves or stands, there is a constant outpouring of epinephrine and norepinephrine. It is for this reason that POTS is so often misdiagnosed as anxiety.

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