Postural Orthostatic Tachycardia Syndrome (POTS) Treatment in Delhi, India

Postural orthostatic tachycardia syndrome is a disorder of the autonomic nervous system. It is characterized by a sudden increase in a heartbeat when the person tends to get up and stand from a lying down or sitting position. Besides the increased heart rate, a person also experiences fatigue and dizziness.

In people with POTS, these blood vessels don't act efficiently to get the signal to tighten up considerably. So, when the person is standing upright for a longer time, more blood pools up in the lower part of the body. This leads to an inadequate amount of blood returning to the brain, which can be manifested as dizziness and fatigue. During this period, the nervous system continues to work towards releasing hormones epinephrine and norepinephrine to tighten the blood vessels. This results in an increase in heart rate and further results in instability, nausea and chest pain.

Types of POTS

POTS are classified as follows:

• Hyperadrenergic POTS: Hyperadrenergic refers to increased adrenaline or epinephrine. Adrenaline and nor-adrenaline (epinephrine and norepinephrine) present in the body act as natural stimulants that are released during fight or flight response. Patients with hyperadrenergic POTS have more norepinephrine content in their blood. It leads to increased heart rate and blood pressure.
• Neuropathic POTS: Neuropathic relates to diseases of the nerves. In neuropathic POTS, the sympathetic nerve supply to the lower limbs doesn't function well. As a result, the blood will accumulate in the lower part rather than return to the heart. This causes dizziness while standing (orthostasis) and increases heart rate (tachycardia). This type of POTS is a more common one.
• Secondary POTS: Secondary POTS is a syndrome that occurs as a result of another underlying condition resulting in the damage of the nerves which control the distribution of blood. The underlying conditions may be diabetes, lupus, alcoholism, and chemotherapy.

Symptoms of POTS

POTS presents various symptoms, and they differ from person to person. Various symptoms associated with POTS are as follows:

• Anxiety
• Nervousness
• Fatigue
• Heart palpitations
• Headache
• Bloating
• Chest pain
• Dyspnoea
• Dizziness
• Fainting
• Pale face
• Discolouration of extremities
• Disturbed sleep
• Inability to concentrate properly
• Excessive sweating
• Vomiting
• Exercise intolerance

The symptoms tend to get worse in the following conditions:

• In warm environments like a very hot day or while taking a hot shower
• Situations demanding a lot of standing, like shopping or standing in a queue
• Inadequate fluid and salt intake, such as being hungry for a longer time period
• Indulging in strenuous workout
• During menstruation.

Diagnosis of POTS

POTS can be difficult to diagnose due to the wide range of symptoms that take place over a period of time. People with POTS develop symptoms slowly, ranging from a few months to years before finally being diagnosed with the condition. Patients undergo a wide range of tests to confirm their diagnosis. These are as follows:

• Tilt table test: The heart rate and blood pressure are measured while making the person lie on a tilt table that can be titled or moved upright. The readings are taken various times while the bed is slowly moved and tilted into a more upright position.
• Active stand test: The heart rate and blood pressure levels are measured after lying down and then immediately upon standing and repeated after 2, 5 and 10 minutes.
• Electrocardiogram (ECG): It records the heart's electrical activity.
• Echocardiogram: This refers to an ultrasound scan of the heart.
• 24-hour ambulatory monitoring of vitals: In this activity, small devices are attached to the body, which take regular readings while the patients perform normal activities.
• Blood tests and urine culture: Determine the kidney, liver and thyroid functioning and measure blood count, calcium and glucose levels.
• Autonomic breathing test: It measures the rate of blood and pressure response during exercise.
• QSART: It is to measure the autonomic nerves that control sweating.
• Skin biopsy for small fibre sensory neuropathy.

Treatment for POTS

This condition of POTS varies from person to person. Doctors treat this condition according to the symptoms presented by the patients. The main forms of treatment options available are as follows:

1. Exercise: Exercise plays a vital role in managing the symptoms of POTS. These are categorized as follows:
• Cardiac Rehabilitation Program:It improves the endurance, stamina and overall health of the patients. This is followed by swimming and cycling for the best possible results.
• Aquatic Therapy:It proves beneficial in the treatment because of the pressure created by the water around an individual's body.
• Physical Therapy: It provides a lot of relief to patients with POTS. However, one thing to be kept in mind here is that patients need to start their exercise on a slow basis, and they can never push or stretch their body while doing exercises as it worsens the symptoms instead of giving relief.
• The main aim of exercise therapy is to guide the autonomic nervous system to allow for more exercise, which in turn helps increase the volume of blood.
• Physical therapy comprises doing isometric exercises, which involve the contraction of muscles without actually moving the body. Isometric exercises tend to squeeze the muscles tightly and push back the flow of blood towards the heart.
2. Use of fitness trackers:It helps to count the number of steps on a daily basis. Patients must note how many steps they can walk without the onset of symptoms. They can take this as an initial baseline and then increase the steps accordingly after a few days once they improve with exercises.
3. Change of position: It is recommended to change positions slowly without hurry. While lying down in bed, it is recommended to move from lying to a sitting position and be in that position for a few minutes. Afterwards, the individual can stand upright finally without producing any symptoms.
4. Yoga:Start doing yoga and meditation on a regular basis.
5. Diet control:Managing diet and nutrition also controls the symptoms of POTS. It is advised to increase salt and fluid intake in the diet to improve blood volume. General guidelines for dietary changes include:
• Consume 2 to 2.5 litres per day of fluids.
• Taking small and intermittent meals instead of a few large meals with longer breaks in between.
• Consumption of a high-fibre diet and carbohydrates helps in the reduction of blood glucose levels and reduces the symptoms of POTS.
• Include things like broth, pickles, olives, sardines, anchovies and nuts in the diet.
6. Medications

Prevention of POTS

• Avoid standing for a prolonged period of time.
• Maintain constant temperature.
• Avoid smoking and alcohol.
• Avoid having a nap during the day.
• Reducing screen time, such as viewing television or using phones till late at night, can interfere with proper sleep patterns, thereby increasing the symptoms of POTS.
• Elevate the head end of the bed approximately six to ten inches to alleviate POTS symptoms.

Outlook of POTS

The prognosis for POTS is ideally very good, although the biggest risk to people with POTS is getting injured if they fall suddenly because of dizziness. It can severely disrupt daily living. POTS symptoms may reoccur and accordingly subside for years. In the majority of cases, the overall condition of the patient improves significantly, but many people are left with residual symptoms.

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