Exercise training versus propranolol in the treatment of the postural orthostatic tachycardia syndrome
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We have found recently that exercise training is effective in the treatment of the postural orthostatic tachycardia syndrome (POTS). Whether this nondrug treatment is superior to “standard” drug therapies, such as β-blockade, is unknown. We tested the hypothesis that exercise training but not β-blockade treatment improves symptoms, hemodynamics, and renal-adrenal responses in POTS patients. Nineteen patients (18 women and 1 man) completed a double-blind drug trial (propranolol or placebo) for 4 weeks, followed by 3 months of exercise training. Fifteen age-matched healthy individuals (14 women and 1 man) served as controls. A 2-hour standing test was performed before and after drug treatment and training. Hemodynamics, catecholamines, plasma renin activity, and aldosterone were measured supine and during 2-hour standing. We found that both propranolol and training significantly lowered standing heart rate. Standing cardiac output was lowered after propranolol treatment ( P =0.01) but was minimally changed after training. The aldosterone:renin ratio during 2-hour standing remained unchanged after propranolol treatment (4.1±1.7 [SD] before versus 3.9±2.0 after; P =0.46) but modestly increased after training (5.2±2.9 versus 6.5±3.0; P =0.05). Plasma catecholamines were not affected by propranolol or training. Patient quality of life, assessed using the 36-item Short-Form Health Survey, was improved after training (physical functioning score 33±10 before versus 50±9 after; social functioning score 37±9 versus 48±6; both P <0.01) but not after propranolol treatment (34±10 versus 36±11, P =0.63; 39±7 versus 39±5, P =0.73). These results suggest that, for patients with POTS, exercise training is superior to propranolol at restoring upright hemodynamics, normalizing renal-adrenal responsiveness, and improving quality of life.
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Treatments that improve symptoms of POTS might decrease the occurrence of syncope.
“Treatments that improve symptoms of POTS might decrease the occurrence of syncope, although this is unknown (24,514–523).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [517]
The Results (Exercise Training; page unavailable) report improved quality of life and presyncope in three patients before training versus one afterward. The Discussion (Perspectives; page unavailable) says exercise improved POTS symptoms. Presyncope is not syncope, however, and the paper does not establish or explicitly propose that symptom-improving treatments decrease syncope occurrence. (LLM, conf=0.84)
Experimental — accuracy not yet measuredLong-acting propranolol does not improve quality of life in POTS patients.
“Long-acting propranolol does not improve the quality of life of patients with POTS,43”
Although long-acting propranolol has been demonstrated to reduce standing HR in POTS, this medication did not improve quality of life.
“However, although long-acting propranolol has been demonstrated to reduce standing HR in POTS, this medication did not improve quality of life (98).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [98]
In a double-blind drug trial, propranolol was effective at reducing standing HR, but exercise training was superior to propranolol at restoring upright hemodynamics and normalizing renal-adrenal responsiveness.
“Even though propranolol was also effective at reducing standing HR, exercise training was found to be superior to propranolol at restoring upright hemodynamics and normalizing renal-adrenal responsiveness.”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [98]
Patient quality of life improved after exercise training but not with propranolol treatment.
“Patient quality of life also improved after exercise training, but not with propranolol treatment (98).”
From Postural Orthostatic Tachycardia Syndrome (2019) · cites this paper as [98]
The three-month Dallas Program, involving aerobic exercise and resistance training, improves orthostatic and exercise tachycardia, symptoms, and quality of life in POTS.
“The three-month Dallas Program, which involves aerobic exercise coupled with resistance training, improves orthostatic and exercise tachycardia, symptoms, and quality of life [13;62;63].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [62]
Long-acting propranolol did not improve quality of life in that trial.
“The decrease in standing HR was verified in a four-week trial of long-acting propranolol although quality of life was not improved [62].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [62]
Long-acting propranolol reduced standing heart rate over a four-week trial.
“The decrease in standing HR was verified in a four-week trial of long-acting propranolol although quality of life was not improved [62].”
From Postural tachycardia syndrome: beyond orthostatic intolerance (2015) · cites this paper as [62]
Long-acting, once-daily propranolol did not improve quality of life at one month in POTS patients.
“In contrast, Fu et al. (64) showed that the long-acting, once-daily formulation of propranolol did not improve quality of life at one month.”
From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [64]
Exercise is the only intervention that has been shown to improve the aldosterone:renin ratio and increase plasma and blood volumes chronically.
“Exercise is the only intervention that has been shown to improve the aldosterone:renin ratio and increase plasma and blood volumes chronically (64).”
From Postural orthostatic tachycardia syndrome: mechanisms and new therapies (2020) · cites this paper as [64]
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Impact of exercise to treat postural orthostatic tachycardia syndrome: a systematic review
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- Authors
- Fu, Q., VanGundy, T. B., Shibata, S., Auchus, R. J., Williams, G. H., & Levine, B. D.
- Affiliations
- Brigham and Women's Hospital (US)
- Venue
- Hypertension
- Published
- 2011-08
- Volume
- 58
- Issue
- 2
- Pages
- 167-175
- ISSN
- 0194-911X (ISSN-L)
- 1524-4563
- PMC
- PMC3142863
- OpenAlex
- W2150733776
- Cited by
- 175
- References
- 45
- Citations by year
- 2026: 9 · 2025: 15 · 2024: 13 · 2023: 17 · 2022: 13 · 2021: 10 · 2020: 15 · 2019: 12 · 2018: 7 · 2017: 11 · 2016: 8 · 2015: 6 · 2014: 15 · 2013: 10 · 2012: 11
- FWCI
- 12.45
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Hypertension (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (HL075283, K23HL075283)
- National Cancer Institute (CA00701)
- National Center for Research Resources (RR 00633, M01RR000633)
- 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 › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Keywords
- postural orthostatic tachycardia syndrome, exercise training, propranolol, beta-adrenergic blockade, aldosterone, plasma renin activity, catecholamines, cardiac output, hemodynamics, quality of life, non-pharmacological treatment
- MeSH terms
- Adrenergic beta-Antagonists, Adult, Aldosterone, Blood Pressure, Double-Blind Method, Exercise Therapy, Female, Health Surveys, Heart Rate, Hemodynamics, Humans, Male, Propranolol, Quality of Life, Renin, Treatment Outcome, Postural Orthostatic Tachycardia Syndrome
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