Postural Tachycardia Syndrome (POTS)
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The HRPeak during head-up tilt was lower with both ivabradine and propranolol.
“The HRPeak during HUT was also lower with both drugs, reinforcing their ability to blunt excessive orthostatic tachycardia, the key physiological impact of POTS.2,3”
From A Randomized Crossover Trial of Ivabradine, Propranolol, and Placebo in Postural Orthostatic Tachycardia Syndrome (2026) · cites this paper as [2]
This is felt to be a reflection of exaggerated sympathetic neuronal activation.
“This is felt to be a reflection of exaggerated sympathetic neuronal activation (97).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [97]
A diagnosis of POTS requires chronic orthostatic symptoms lasting more than six months and exclusion of prolonged bedrest, deconditioning, medications that impair autonomic regulation, and other chronic debilitating disorders that can cause tachycardia.
“The HR abnormality must be accompanied by chronic (>6 months) orthostatic symptoms that occur in the absence of prolonged bedrest or deconditioning, use of medications that impair autonomic regulation (vasodilators, diuretics, antidepressants, or anxiolytic agents), or other chronic debilitating disorders that might cause tachycardia (such as dehydration, anemia, or hyperthyroidism) [19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
When measured during upright posture, norepinephrine is elevated in many POTS patients (>3.55 nmol/L and sometimes >5.91 nmol/L), consistent with sympathetic neuronal activation elicited by standing.
“When measured during upright posture, norepinephrine is elevated in many patients with POTS [>3.55 nmol/L (600 pg/mL) and sometimes >5.91 nmol/L (1000 pg/mL)], consistent with the sympathetic neuronal activation elicited by standing in these patients [19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Central sympatholytics such as clonidine and methyldopa can reduce sympathetic tone in POTS patients with prominent hyperadrenergic features.
“Central sympatholytics (e.g. clonidine and methyldopa) can also be used to decrease sympathetic tone in patients with prominent hyperadrenergic features, but might produce drowsiness and worsening of the mental clouding [19] (HRS Class IIb) [8].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Abdominal compression with elastic waist-high support hose and abdominal binders can help decrease splanchnic-mesenteric venous pooling during standing, and the increase in venous return and stroke volume can decrease orthostatic tachycardia.
“Abdominal compression with elastic waist-high support hose and abdominal binders can help decrease splanchnic-mesenteric venous pooling during standing [43]. The increase in venous return and stroke volume can decrease the orthostatic tachycardia [19;59].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Central sympatholytics may cause drowsiness and worsen mental clouding in POTS patients.
“Central sympatholytics (e.g. clonidine and methyldopa) can also be used to decrease sympathetic tone in patients with prominent hyperadrenergic features, but might produce drowsiness and worsening of the mental clouding [19] (HRS Class IIb) [8].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
More generalized complaints in POTS include hypermobile joints, exercise intolerance, migraine headaches, sleep disturbances, and fatigue.
“More generalized complaints in patients with POTS include hypermobile joints, exercise intolerance, migraine headaches, sleep disturbances, and fatigue [19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Excessive tachycardia in POTS occurs during exercise as well as standing, and patients experience significant exercise intolerance.
“Excessive tachycardia in POTS occurs during exercise as well as during standing [60;61], and patients experience significant exercise intolerance [9;19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Autonomic problems in POTS may include gastrointestinal complaints, bladder symptoms, and abnormal sudomotor regulation.
“Autonomic problems in POTS might include gastrointestinal complaints, such as abdominal pain, nausea and irritable bowel syndrome, as well as bladder symptoms and abnormal sudomotor regulation [19;26].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
POTS patients often have a vigorous pressor response with exaggerated BP recovery and overshoot before and after release during Valsalva.
“Patients with POTS often have a vigorous pressor response, with exaggerated BP recovery and overshoot both before and after release [19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
The heart rate abnormality and orthostatic symptoms in POTS should not be caused by medications that impair autonomic regulation or by debilitating disorders that can cause tachycardia.
“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.”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Fludrocortisone stimulates potassium excretion, requiring monitoring for hypokalemia.
“Fludrocortisone also stimulates potassium excretion, making it necessary to watch for hypokalemia, and it can also worsen migraine headaches [71;19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Fludrocortisone can worsen migraine headaches.
“Fludrocortisone also stimulates potassium excretion, making it necessary to watch for hypokalemia, and it can also worsen migraine headaches [71;19].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [19]
Pyridostigmine enhances cholinergic activity at both ganglionic nicotinic and postganglionic muscarinic acetylcholine receptors, with a likely net increase in parasympathetic nervous system tone.
“Pyridostigmine enhances cholinergic activity at both the ganglionic nicotinic and the postganglionic muscarinic acetylcholine receptors, with a likely net increase in parasympathetic nervous system tone (3).”
From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [3]
Cites
Orthostatic Intolerance and Tachycardia Associated with Norepinephrine-Transporter Deficiency
Shannon, J. R., Flattem, N. L., Jordan, J., Jacob, G., Black, B. K., Biaggioni, I., Blakely, R. D., & Robertson, D. (2000) · New England Journal of Medicine · doi:10.1056/nejm200002243420803 · Cited by 594 · see citing works
The neuropathic postural tachycardia syndrome
Jacob, G., Costa, F., Shannon, J. R., Robertson, R. M., Wathen, M., Stein, M., Biaggioni, I., Ertl, A., Black, B., & Robertson, D. (2000) · New England Journal of Medicine · doi:10.1056/nejm200010053431404 · Cited by 398 · see citing works
Cardiac origins of the postural orthostatic tachycardia syndrome
Fu, Q., VanGundy, T. B., Galbreath, M. M., Shibata, S., Jain, M., Hastings, J. L., Bhella, P. S., & Levine, B. D. (2010) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2010.02.043 · Cited by 329 · see citing works
Raj, S. R., Biaggioni, I., Yamhure, P. C., Black, B. K., Paranjape, S. Y., Byrne, D. W., & Robertson, D. (2005) · Circulation · doi:10.1161/01.cir.0000160356.97313.5d · Cited by 286 · see citing works
Self-citationRaj, S. R., Black, B. K., Biaggioni, I., Paranjape, S. Y., Ramirez, M., Dupont, W. D., & Robertson, D. (2009) · Circulation · doi:10.1161/circulationaha.108.846501 · Cited by 225 · cited 1× · see citing works
“19 More complete β-blockade, however, is less well tolerated.(19) Pyridostigmine is a peripheral acetylcholinesterase inhibitor that can increase the levels of synaptic acetylcholine at both the autonomic ganglia and peripheral muscarinic parasympathetic receptors.”
BackgroundSelf-citationHyperadrenergic Postural Tachycardia Syndrome in Mast Cell Activation Disorders
Shibao, C., Arzubiaga, C., Roberts, L. J., Raj, S., Black, B., Harris, P., & Biaggioni, I. (2005) · Hypertension · doi:10.1161/01.hyp.0000158259.68614.40 · Cited by 220 · see citing works
Self-citationQuality of Life in Patients With Postural Tachycardia Syndrome
Benrud-Larson, L. M., Dewar, M. S., Sandroni, P., Rummans, T. A., Haythornthwaite, J. A., & Low, P. A. (2002) · Mayo Clinic Proceedings · doi:10.4065/77.6.531 · Cited by 217 · see citing works
Postural tachycardia in children and adolescents: what is abnormal?
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Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia
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Self-citationThe hemodynamic and neurohumoral phenotype of postural tachycardia syndrome
Garland, E. M., Raj, S. R., Black, B. K., Harris, P. A., & Robertson, D. (2007) · Neurology · doi:10.1212/01.wnl.0000267663.05398.40 · Cited by 159 · see citing works
Self-citationSleep Disturbances and Diminished Quality of Life in Postural Tachycardia Syndrome
Bagai, K., Song, Y., Ling, J. F., Malow, B., Black, B. K., Biaggioni, I., Robertson, D., & Raj, S. R. (2011) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.28110 · Cited by 134 · see citing works
Self-citationPsychiatric profile and attention deficits in postural tachycardia syndrome
Raj, V, Haman, K. L., Raj, S. R., Byrne, D., Blakely, R. D., Biaggioni, I., Robertson, D., & Shelton, R. C. (2009) · Journal of Neurology, Neurosurgery & Psychiatry · doi:10.1136/jnnp.2008.144360 · Cited by 131 · see citing works
Self-citationSelective Norepinephrine Reuptake Inhibition as a Human Model of Orthostatic Intolerance
Schroeder, C., Tank, J., Boschmann, M., Diedrich, A., Sharma, A. M., Biaggioni, I., Luft, F. C., & Jordan, J. (2002) · Circulation · doi:10.1161/hc0302.102597 · Cited by 127 · see citing works
Pyridostigmine in the treatment of postural orthostatic tachycardia: a single-center experience
KANJWAL, K., KARABIN, B., SHEIKH, M., ELMER, L., KANJWAL, Y., SAEED, B., & GRUBB, B. P. (2011) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2011.03047.x · Cited by 106 · cited 2× · see citing works
“Pyridostigmine 30 to 60 mg orally 3 times a day has been reported to result in long-term symptom improvement in ≈50% of POTS patients.(20) Pyridostigmine can enhance bowel motility; thus, gastrointestinal adverse events are the most common reason for discontinuation of the drug.”
BackgroundCoffin, S. T., Black, B. K., Biaggioni, I., Paranjape, S. Y., Orozco, C., Black, P. W., Dupont, W. D., Robertson, D., & Raj, S. R. (2012) · Heart Rhythm · doi:10.1016/j.hrthm.2012.05.002 · Cited by 88 · see citing works
Self-citationCutaneous neuronal nitric oxide is specifically decreased in postural tachycardia syndrome
Stewart, J. M., Medow, M. S., Minson, C. T., & Taneja, I. (2007) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.00600.2007 · Cited by 68 · see citing works
Abnormalities of angiotensin regulation in postural tachycardia syndrome
Mustafa, H. I., Garland, E. M., Biaggioni, I., Black, B. K., Dupont, W. D., Robertson, D., & Raj, S. R. (2011) · Heart Rhythm · doi:10.1016/j.hrthm.2010.11.009 · Cited by 62 · see citing works
Self-citationDiurnal variability in orthostatic tachycardia: implications for the postural tachycardia syndrome
Brewster, J. A., Garland, E. M., Biaggioni, I., Black, B. K., Ling, J. F., Shibao, C. A., Robertson, D., & Raj, S. R. (2012) · Clinical Science · doi:10.1042/cs20110077 · Cited by 56 · see citing works
Self-citationGynecologic disorders and menstrual cycle lightheadedness in postural tachycardia syndrome
Peggs, K. J., Nguyen, H., Enayat, D., Keller, N. R., Al‐Hendy, A., & Raj, S. R. (2012) · International Journal of Gynecology & Obstetrics · doi:10.1016/j.ijgo.2012.04.014 · Cited by 51 · cited 1× · see citing works
“About 80% of female patients report an exacerbation of symptoms around menstruation.(5) Many patients have been codiagnosed with irritable bowel syndrome; some have hypermobile joints; and some have abnormal sudomotor regulation.”
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Self-citationDiurnal variability in orthostatic tachycardia: implications for the postural tachycardia syndrome
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Thijs, R. D., Brignole, M., Falup‐Pecurariu, C., Fanciulli, A., Freeman, R. L., Guaraldi, P., Jordan, J., Habek, M., Hilz, M. J., Traon, A. P., et al. (2021) · Autonomic Neuroscience · doi:10.1016/j.autneu.2021.102792 · Cited by 55 · see citing works
Risk Factors for Postural Tachycardia Syndrome in Children and Adolescents
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“The most marked physiologic feature of POTS is an excessive increase in heart rate that occurs on standing in the absence of hypotension [3], and POTS is associated with a very poor quality of life and considerable functional disability [5,6].”
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- Authors
- Raj, S. R.
- Affiliations
- Vanderbilt University (US)
- Corresponding author
- Raj, Satish R.
- ORCID
- Raj, Satish R.
- Venue
- Circulation
- Published
- 2013-06-11
- Volume
- 127
- Issue
- 23
- Pages
- 2336-2342
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC3756553
- OpenAlex
- W2162352430
- Cited by
- 320
- References
- 20
- Citations by year
- 2026: 22 · 2025: 21 · 2024: 21 · 2023: 24 · 2022: 26 · 2021: 23 · 2020: 26 · 2019: 23 · 2018: 28 · 2017: 28 · 2016: 20 · 2015: 14 · 2014: 17 · 2013: 2 · 2012: 1
- FWCI
- 17.43
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (UL1TR000445)
- National Heart, Lung, and Blood Institute (P01HL056693, R01HL102387, P01 HL-56693)
- National Institute of Neurological Disorders and Stroke (U54NS065736)
- National Center for Advancing Translational Sciences
- 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, autonomic dysfunction, heart rate, blood pressure
- MeSH terms
- Contraindications, Adult, Androstenes, Anxiety, Blood Volume, Cardiovascular Agents, Combined Modality Therapy, Confusion, Diagnosis, Differential, Fatigue, Female, Hemodynamics, Humans, Leg, Mast Cells, Norepinephrine, Posture, Renin-Angiotensin System, Sodium Chloride, Sympathetic Nervous System, Syncope, Syndrome, Tachycardia, Catheter Ablation, Norepinephrine Plasma Membrane Transport Proteins
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