Postural tachycardia syndrome is a condition which has been recently described in the medical literature
perhaps over the last 25 years.
But actually, the first reports of this condition were as long ago as 150 years
when physicians recorded a condition of irritable heart syndrome.
The term postural tachycardia syndrome is rather complex and medically confusing. What
it refers to in lay terms is elevated heart rate when changing posture and particularly
when becoming upright from a seated or lying position.
Now the important thing here is that
there is a formal definition of the condition which requires the heart rate to be raised
either above 120 beats per minute
or by more than 30 beats per minute from the resting heart rate
and that this needs to happen within 10 minutes of standing
and also this needs to be sustained.
Importantly, with this condition, blood pressure changes are not supposed to be observed
and do not form part of the diagnosis.
However, the patients will often complain of symptoms or feeling dizzy or lightheaded;
suggesting perhaps that the blood pressure has gone down
when in fact it is not supposed to have.
The kind of person that most commonly seems to experience symptoms of POTS or postural
tachycardia syndrome are women of childbearing age and pre-menopausal.
The funny thing here is that you're much more likely to have POTS if you're a young woman
perhaps four or five times more likely than your male equivalent.
The thing here is that there are men that have the symptom of POTS,
but we don't see them as much in the clinic
and perhaps the females are over-represented to an extent
because they can often have quite debilitating symptoms related to the condition.
This makes it quite challenging to look after them,
but nonetheless, we have to try and find ways in which we can both diagnose this condition
and help to treat the patients whilst being sympathetic to their needs.
The symptoms of the postural tachycardia syndrome are varied
and reflect the complexity of the medical condition that it represents.
For instance, when one thinks of POTS or postural tachycardia syndrome,
one has to imagine that the patient can have involvement of the heart and the circulation.
They can have involvement of the gut, they can have involvement of the bladder.
Underlying this may be a tendency to joint hypermobility syndrome
as well as having significant cognitive and behavioural issues.
Starting with the circulation, patients most commonly will complain of dizziness.
although, out and out fainting is not that common -
perhaps less than 30 percent of patients will experience what we call syncope or faints.
In a number of patients, change in posture results in dizziness. Either when getting up from lying
or when arising from seated.
The thing here is that we're not supposed to be
diagnosing blood pressure change at the same time as the dizziness.
And this can often lead other practitioners to somewhat be sceptical about the patient's complaint
as they cannot find a reason for the symptoms of dizziness.
The other predominant cardiac symptom that these patients complain about
is of heart rate elevation or "palpitations".
This can sometimes be quite anxiety provoking for understandable reasons.
Sometimes the heart rates can go exceedingly high indeed in the absence of any other provocation.
And this can cause distress for a number of the patients.
Other symptoms that can arise in the postural tachycardia syndrome relate
to the gut and involve features of irritable bowel syndrome including bloating, constipation,
tummy pain, sometimes change in bowel habit as well.
All in all these symptoms can also be quite distressing for a number of our patients
and they do require specialised input to help with the management.
One of the most important aspects of POTS that is only getting recognition in the recent times
is that of the psychological disturbances that can arise with this condition.
What we have come to recognise is increasing symptoms of anxiety and depression in patients
with POTS. In addition to this, they can also complain of problems with attention, memory,
and executive function function, i.e., their ability to complete tasks.
At present it is not known the best approach to manage these sorts of symptoms.
Although, one would think that a psychologist or psychotherapist might be the appropriate person
to help out in this instance.
The other aspect of POTS that requires medical input due to symptoms is of the hypermobility
spectrum disorders, which often accompany this disorder.
This can result in patients having issues with joint aches and pains or even joint dislocations
tendency to spraining of ligaments, a tendency to easy bruising,
and a tendency to scars that heal poorly.
All in all these are best managed by rheumatologists.
The most common way for people to present with POTS either men or women is with the
heart rate disturbances that come with this condition.
This involves symptoms of unexpected palpitations or dizziness and the tendency
to feeling very lightheaded when changing posture.
At this point in time, the physician may be somewhat confused by the presentation
of the patient, because the heart rate elevation is unexpected and there is no blood pressure change
when the patient complains of dizziness.
However, these to me are hallmarks of the postural tachycardia syndrome.
And at this point probably the patient is best off seeking specialist input.
The very important thing to realise is that there is no one specialist
that is able to manage all the aspects of POTS, which we are increasingly recognising
to be a complex multi system disorder.
Having said that, that is not a cause to despair
because there are specialists around who have interest in this condition and have the competency
to be able to help patients with these complaints.
All in all, the most important thing is to identify
clinicians who are regularly seeing patients with the postural tachycardia syndrome
and who have established good networks of care that involve good communication between
the physicians and the patients, so that a holistic approach can be taken to help with
patient care and to support the patient in what is often a very challenging clinical
environment.
The treatment for postural tachycardia syndrome really depends
on what the patient's principal complaint is.
If we focus on the cardiovascular system which is my area of expertise, then
we would be talking about how to manage palpitations, which is rapid heart rate, or dizziness, which
is the tendency to feel almost like fainting or actually going on to having a franc faint.
With the symptoms of rapid heart rate and dizziness, there are drug treatments to manage
their patients, but the first instance, we always try and use non-pharmacological or
non-drug treatments.
This would consist of supporting the circulation with increased salt and fluid intake,
avoiding dehydration, avoiding excessive hot weather.
We would also recommend avoidance of caffeinated products
and usually alcohol is not well-tolerated by these patients.
Other physical manoeuvres that patients can undertake to avoid dizziness
and palpitations include being careful about change in posture.
For instance, getting up slowly from a seated position and avoiding running upstairs.
Patients with POTS often don't tolerate being stood up for a long time in any one place
and we would advise them that if they are queuing somewhere to be marching on the spot
or to use rapid leg alternating movements
or even stooping to prevent the fluid accumulating in the lower limbs.
Other treatments that we recommend for patients to avoid dizziness and palpitations include
use of compression hosiery. This involves compression stockings to the legs usually
in the form of low limb. Grade two graduated compression stockings that are thigh length
because ones that are below the knee are no good.
Furthermore, some of our patients require abdominal compression garments
such as corsets or binders, which can also help to prevent dizziness.
When one talks about drug treatment of POTS, there are only a few options.
And the key thing here is that the treatments are tolerated well by the patients
which drugs are not always the case.
So we use drugs such as Wellbutrin or Beta Blockers to keep the heart rate under control
but by and large I try and minimise the use of medication where possible
in this patient group.