What is Postural Tachycardia Syndrome?

Postural tachycardia syndrome (POTS) is an abnormally high increase in heart rate that occurs after sitting up or standing. Typical symptoms of POTS include dizziness or lightheadedness, fainting, brain fog, heart palpitations, shortness of breath, feeling sick, weakness and fatigue, sweating and poor sleep.

POTS can affect anyone, but is most common in women aged 15 to 50. For many patients, symptoms are mild, but for others, POTS can significantly impact their quality of life making it impossible to live their life without constantly having to think about it.  

What happens to the brain with POTS?

When someone goes from lying to standing, gravity pulls blood down towards their feet. Baroreceptors in the neck inform the brain that pressure in neck blood vessels has reduced. The vestibular system informs the brain about changes against gravity and fires reflexes that constrict blood vessels. These happen so that blood can be pumped back up to the brain. These reflexes work poorly with POTS, and blood flow to the brain subsequently decreases. I like to say my patients with POTS are “gravity intolerant.” This is a significant challenge because gravity and movement are the two constants acting on our brain whenever we are not laying still. POTS patients always report feel best when laying down.

The brain will normally increase the heart rate 10-20BPM to compensate for a lack of blood getting to the brain or slightly increase diastolic blood pressure (the lower number in a blood pressure reading). With POTS, the increase in heart rate is extreme (orthostatic tachycardia) while blood pressure stays the same or increases, or there is a severe drop in blood pressure of more than 20/10mmHg (orthostatic hypotension).

Your brain requires oxygen and glucose (sugar) to properly function and gets these both from blood. When its supply is disrupted, simple cognitive tasks can become profound challenges and simple physical tasks may become exhausting. Everything your brain does depends on the ability to properly regulate blood flow. When this fails, virtually everything your brain attempts to do can become a struggle.

 How is POTS diagnosed?

There are specific diagnostic criteria for POTS. To be diagnosed:

1. Your heart rate must increase by 30 beats a minute (BPM), or over 120BPM, within 10 minutes of standing from a laying position and must remain increased for more than 30 seconds.  

2. Symptoms get worse with standing and better with laying down.

3. Symptoms last for 6 months or more.

4. Standing blood levels of norepinephrine are greater than or equal to 600pg/mL.

5. Absence of other causes of orthostatic symptoms or tachycardia (like meds, acute dehydration or active bleeding).

At Anew, we offer tilt table testing, which is the most common and standard for POTS diagnosis. During a tilt table test, we measure your heart rate as you change posture and position gradually over time. Some providers also do blood tests, ECGs, echocardiograms, or the active stand test to diagnose POTS. POTS patients usually have low blood volume and low blood pressure.

How is POTS usually treated?

There is no known established cure for POTS in conventional medicine or in typical internet searches, however I treat it in my clinic all the time. Most cases are reportedly managed through lifestyle changes, diet, and physical exercise. Some patients may take medication.  While these can help mitigate some of the symptoms of POTS, they generally do little to affect the impaired autonomic reflexes that are the underlying cause of the disorder.

 The primary job of your brain is help you determine where you are in the world. Your brain uses inputs from your inner ear to figure out where your head is in relation to gravity. It uses inputs from your muscles and joints to figure out where your body is in relation to gravity and in relation to your head. It uses inputs from your eyes to figure out where your body is in relation to the surrounding environment.  

Your brain needs to put all of that together to make sense of where the world is, and where you are in relation to the world, in order for you to be able to respond to the environment properly.

Your brain organizes all this information in terms of maps. There is a vestibular map from the inner ear, a proprioceptive map from muscles and joints, a vascular map of your blood flow, a visual map of the world from your eyes, and several others. Your brain needs these maps to be saying largely the same thing for efficient and effective function.

One often overlooked feature of POTS is that these maps usually fail to match. Your eyes, inner ear and muscles are creating maps that say different things about where your head is in relation to gravity. When you go from lying down to standing, problems in these maps can make it difficult for the brain to compensate for the postural shift against gravity. If the brain does not understand the position of the head in relation to gravity, it cannot properly control the vascular system to send the appropriate amount of blood to the head.

This is why many patients fail to fully resolve their POTS with most forms of treatment. Without addressing the problems in these maps, it will remain impossible for the brain to properly control blood flow, and the best they can hope for is to gain some control over their symptoms. We would much rather try to address the underlying cause.

At Anew, we design a tailored program that’s unique to your brain and your injury using the most comprehensive diagnostic and therapeutic protocols available today.  By focusing on the integration of the important systems your brain is relying on, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to return you to living a healthy, vibrant, and fulfilling life.