Postural tachycardia syndrome (POTS)
Open accessAbstract
Postural Tachycardia Syndrome. Introduction: POTS is defined as the development of orthostatic symptoms associated with a heart rate (HR) increment ≥30, usually to ≥120 bpm without orthostatic hypotension. Symptoms of orthostatic intolerance are those due to brain hypoperfusion and those due to sympathetic overaction. Methods: We provide a review of POTS based primarily on work from the Mayo Clinic. Results: Females predominate over males by 5:1. Mean age of onset in adults is about 30 years and most patients are between the ages of 20–40 years. Pathophysiologic mechanisms (not mutually exclusive) include peripheral denervation, hypovolemia, venous pooling, β‐receptor supersensitivity, psychologic mechanisms, and presumed impairment of brain stem regulation. Prolonged deconditioning may also interact with these mechanisms to exacerbate symptoms. The evaluation of POTS requires a focused history and examination, followed by tests that should include HUT, some estimation of volume status and preferably some evaluation of peripheral denervation and hyperadrenergic state. All patients with POTS require a high salt diet, copious fluids, and postural training. Many require β‐receptor antagonists in small doses and low‐dose vasoconstrictors. Somatic hypervigilance and psychologic factors are involved in a significant proportion of patients. Conclusions: POTS is heterogeneous in presentation and mechanisms. Major mechanisms are denervation, hypovolemia, deconditioning, and hyperadrenergic state. Most patients can benefit from a pathophysiologically based regimen of management. (J Cardiovasc Electrophysiol, Vol. 20, pp. 352‐358, March 2009)
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Symptoms of orthostatic intolerance may be accompanied by hemodynamic disturbances, including blood pressure decrease and heart rate increase.
“These symptoms may be accompanied by hemodynamic disturbances, including blood pressure decrease, which may or may not meet criteria for OH, and heart rate increase, which may be inadequate or compensatory (38).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [38]
The Introduction describes excessive tachycardia as a common manifestation of orthostatic intolerance, often without orthostatic hypotension. The HUT and Evaluation of Adrenergic Function section reports that some patients have a fall in blood pressure, supporting the main claim. The paper does not establish the citing sentence’s additional characterization of the heart-rate increase as potentially inadequate; its discussion of compensatory tachycardia concerns exercise. (LLM, conf=0.82)
Experimental — accuracy not yet measuredMost commonly, symptoms of orthostatic intolerance include lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue.
“Most commonly, the symptoms include lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue.”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [38]
The Introduction lists lightheadedness, tremulousness, and exercise intolerance among frequent complaints. Clinical Features names lightheadedness, palpitations, tremulousness, and weakness or heaviness (especially of the legs) as the most common symptoms, and says fatigue is commonly present. The cited text does not mention blurred vision or specifically describe generalized weakness. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe hyperadrenergic subtype may correspond to 30% to 60% of POTS patients.
“Another large subgroup within the POTS population is the so-called hyperadrenergic subtype, with features that may correspond to 30% to 60% of POTS patients (6,36,37).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [36]
The Hyperadrenergic POTS section reports elevated norepinephrine in 29.0% of patients tested, and the HUT and Evaluation of Adrenergic Function section says about half have a hyperadrenergic response. These figures support the claim that hyperadrenergic features occur in a substantial subgroup, but the paper does not establish a 30%–60% prevalence for the subtype, which it defines using both a blood-pressure rise and elevated norepinephrine. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPatients with hyperadrenergic POTS or significant hypertensive responses during tilt may respond to phenobarbital.
“Patients with hyperadrenergic POTS or significant hypertensive responses during tilt may respond to phenobarbital 15 mg in the morning and 60 mg at night (36).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [36]
The Management > Hyperadrenergic POTS passage says that some patients with autonomic instability and unstable hypertensive responses to tilt respond to oral phenobarbital, beginning with 60 mg at night and 15 mg in the morning. It does not extend that treatment response to hyperadrenergic POTS patients generally; it describes a particularly difficult subset. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe standing heart rate in POTS patients is often at least 120 bpm.
“The standing (or orthostatic) heart rate of individuals with POTS is often ≥120 bpm,8–13”
More than 75% of POTS patients are female.
“and more than 75% are female.7–9,11–14,16”
Hyperadrenergic POTS patients have elevated standing plasma norepinephrine levels (>600 pg/ml), reflecting an exaggerated sympathetic response.
“These patients have elevated standing plasma norepinephrine (NE) levels (>600 pg/ml), reflecting an exaggerated sympathetic response (6,36),”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [36]
Clonidine can be used to reduce autonomic instability in similar patients.
“Clonidine (a central sympatholytic) 0.1 mg twice daily can be used to reduce autonomic instability in similar patients (36).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [36]
Prevalence estimates for POTS range from 0.2% to 1% of the US population, suggesting approximately 1-3 million affected persons.
“Estimates, based largely on clinical experience, range from 0.2% and 1% of the US population, which would suggest approximately 1–3 million affected persons (Arnold et al., 2018; Low et al., 2009; Sheldon et al., 2015).”
From Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1 (2021) · cites this paper as Low et al., 2009
POTS patients may have orthostatic hypertension and complain of tremor, anxiety, and cold, sweaty extremities.
“These patients may have orthostatic hypertension (increase in systolic blood pressure >10 mmHg on standing) and complain of tremor, anxiety and cold, sweaty extremities [7;25].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [25]
In addition to orthostatic symptoms, POTS patients experience non-specific signs and symptoms that seem unrelated to postural intolerance or excessive tachycardia.
“In addition to orthostatic symptoms in POTS, patients experience non-specific signs and symptoms that seem unrelated to postural intolerance or excessive tachycardia [25].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [25]
The vast majority of POTS patients are young, with a mean age of presentation between 15-30.
“The vast majority are young, with a mean age of presentation between 15–3034,36.”
From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [36]
POTS has been shown to have a prevalence of 0.2% in cohort studies and predominately affects females at a 5:1 ratio.
“POTS has been shown to have a prevalence of 0.2% in cohort studies31–33 and predominately affects females at a 5:1 ratio.31,34–36”
From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [36]
POTS is excessive sinus tachycardia triggered by minimal physical activity, especially movement to upright posture.
“POTS is excessive sinus tachycardia triggered by minimal physical activity, especially movement to upright posture.36,50,125,171”
From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [36]
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- Authors
- LOW, P. A., SANDRONI, P., JOYNER, M., & SHEN, W.
- Affiliations
- Mayo Clinic (US)
- Venue
- Journal of Cardiovascular Electrophysiology
- Publisher
- Wiley
- Published
- 2009-02-20
- Volume
- 20
- Issue
- 3
- Pages
- 352-358
- ISSN
- 1045-3873 (ISSN-L)
- 1540-8167
- PMC
- PMC3904426
- OpenAlex
- W2061811312
- Semantic Scholar
- b3c6cc27a108a5fd3d5e0f51d71fd0fbfe8a7184
- Cited by
- 358
- References
- 48
- Citations by year
- 2026: 10 · 2025: 25 · 2024: 21 · 2023: 19 · 2022: 27 · 2021: 18 · 2020: 32 · 2019: 19 · 2018: 20 · 2017: 25 · 2016: 17 · 2015: 25 · 2014: 22 · 2013: 18 · 2012: 21
- FWCI
- 2.82
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of Cardiovascular Electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Funders
- National Institutes of Health (n01ns032352-003)
- National Institute of Neurological Disorders and Stroke (P01NS044233, P50NS032352, NS-44233, N01 NS032352)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Keywords
- postural orthostatic tachycardia syndrome, orthostatic intolerance, heart rate increase, peripheral denervation, hypovolemia, venous pooling, hyperadrenergic state, head-up tilt, volume status, high-salt diet, postural training, beta-receptor antagonists, vasoconstrictors, psychological factors
- MeSH terms
- Humans, Postural Orthostatic Tachycardia Syndrome
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