How difficult would life be if regulating breath, heart rate, and body temperature weren't automatic functions? Luckily, many of the functions of the human body are not under conscious control; we don't have to think about doing them. Our autonomic nervous system (ANS) controls many of these base-level functions, such as breathing, blood pressure, and normalizing internal temperature.
Our article about the vagus nerve reviewed how the ANS works, showing the difficulty in diagnosing ANS dysfunction because it is involved in so many bodily processes. This article focuses on a common manifestation of ANS dysfunction that is currently getting more attention- Postural Orthostatic Tachycardia Syndrome (POTS). This condition results from a lack of coordination between the ANS heart rate control and the movement of blood to compensate for a change of body position.
Many POTS sufferers may be left with symptoms that last many years (2). The most damaging repercussion of POTS symptoms is the potential to fall or faint. Without the ability to catch oneself, the risk of getting hurt increases with the number of falls. There are many daily symptoms of POTS that may not be life threatening, but can substantially impact quality of life. What is the backstory of this ANS dysfunction? Can POTS be prevented, or at least managed?
What is Postural Orthostatic Tachycardia Syndrome (POTS)?
The name Postural Orthostatic Tachycardia Syndrome tries to capture the entire essence of the disorder (2):
Postural: Referring to the posture or position of the body
Orthostatic: Describing the forces involved in moving the body to an upright position
Tachycardia: Pertaining to a fast-beating heart, exceeding 100 heartbeats a minute
Syndrome: Multiple symptoms occurring at the same time
When standing up or pulling the body into an upright position, gravity will tend to cause blood to flow in the direction of the lower body, leaving the brain and upper body without as much blood flow. The ANS directs the blood vessels in the lower half of the body to constrict, forcing blood up toward the brain, countering the effects of gravity so the brain is properly supplied. POTS is the condition and group of symptoms that occur when the ANS cannot accomplish this counter-balance. In general, when the ANS fails, it may be called "dysautonomia" or "autonomic nervous system dysfunction."
POTS can be a confusing topic to research, as the definition of POTS has significantly changed over time. Originally, it referred only to a type of autonomic dysfunction that included orthostatic intolerance, a sudden onset of symptoms when standing up (4). However, now POTS encompasses conditions that may not include orthostatic intolerance or even autonomic involvement. This is primarily due to research identifying several possible underlying mechanisms and adding these to the disorder (4).
Causes of POTS
Many disorders, conditions, and diseases have been identified as potential drivers of POTS, or at minimum, associated with it. Here is a partial list (3, 5, 6):
Diabetes (most common cause) and pre-diabetes
Autoimmune Diseases (Lupus, Sjogren's, others)
Hypermobility syndromes, including Ehlers-Danlos Syndrome (affects collagen, which affects the integrity of veins and joints)
Infections (Lyme, Epstein-Barr, hepatitis, COVID-19, long COVID
Mitochondrial diseases (diseases affecting the mitochondria inside cells)
Mast Cell Activation Disorders (mast immune cell over-response)
Toxicity (potential harm to the liver due to the harsh chemicals of chemotherapy or the poisoning from heavy metals or alcohol)
Vitamin Deficiencies (lack of nutrients or the condition of anemia)
The COVID-19 Connection
COVID-19 may be driving an uptick in POTS cases (1). POTS was already a common disorder, with estimates of 1-3 million people suffering from the condition in the US (2). Many serious infections have long been associated with the development of POTS (3), not just Covid.
Since COVID-19 is a serious viral infection, a previous bout can increase the risk of developing POTS. The post-infection time can be confusing, especially for long COVID or "COVID long-haulers," where symptoms can linger months or years past the initial infection (1). Long COVID can mask the symptoms of POTS, as there is a significant similarity in symptoms. Indeed, this overlap of symptoms between POTS and long COVID initially caught the attention of doctors who were familiar with POTS. However, there is a worry that doctors unfamiliar with POTS may dismiss specific symptoms as long COVID, and not deliver POTS treatments that would more adequately address the patient's symptoms (1).
Risk Factors / Complications
Until early 2020, statistics indicated that 75-80% of diagnosed POTS patients were female, most being between the ages of 15-25 years old (7). Those who have autoimmune disorders seem more at risk for POTS, as do those who have a family history of it or a "joint hypermobility disorder” (8). Additionally, some events seem to increase the risk of POTS, such as (2):
Having a serious viral infection
Enduring a physical blow to the body, especially a blow to the head
Failing to treat POTS can lead to complications such as injuries associated with falling (fractured or broken bones, trauma to the head, bruises), depression in those whose physical activities are severely restricted, and anxiety stemming from a desire to avoid symptoms.
Symptoms of POTS
POTS manifestations can occur as different combinations of the various symptoms, unique to each person. However, many POTS sufferers will experience one or more of the following (2):
Pronounced dizziness upon standing up, standing for long periods of time, or even during a lengthy walk
Syncope (aka fainting or passing out)
Rapid heartbeat or unusual beat
Lack of energy; feeling depleted
Problems with memory or focusing attention
Feeling shaky and having abnormal amounts of sweat
Aching head or pain in the chest
Not feeling well
Face lacking color (while hands and feet are slightly purple if they are below the level of the heart)
Difficulties sleeping due to pains, rapid heartbeat, or heavy sweating
The best prevention for POTS is maintaining a healthy body and immune system, to become resistant to diseases associated with POTS. Boost the immune system and build resilience to viral infections by focusing on the five pillars of health.
If possible, eliminate medication that can contribute to the problem or mimic POTS symptoms, but only under the advice and supervision of your doctor. A lengthy list of medications that can induce POTS symptoms is listed here.
There are many ways to positively diagnose POTS or arrive at a conclusion by process of elimination. Traditionally, POTS was diagnosed by putting the patient on a "tilt table," which involves measuring blood pressure and heart rate as the table is slowly tilted back and forth such that blood moves toward the head and the feet with the change in gravity (2). The idea is to create the circumstances that can bring out symptoms such as rapid heartbeat or fainting. This type of test can be pretty challenging for POTS sufferers, especially if they experience anxiety about the onset of symptoms.
At Temecula Center for Integrative Medicine (TCIM), we would likely employ our fingertip plethysmography machine to get information about the health of the ANS and the circulatory system. This fantastic device only requires wearing a finger clamp for a few moments (similar to the finger clamp used for measuring pulse and heart rate). Details about our plethysmography testing can be found in this article. Additionally, our Executive Physicals are very thorough and can help cut through the confusion about "mystery symptoms" and long COVID-19.
Potential Available Treatments
Treatments for POTS are highly variable, depending on the findings of the investigation and diagnosis (9). Addressing POTS may mean employing one or more of the following actions:
1. Treating the diseases or conditions associated with increased risk of POTS, such as diabetes.
2. Addressing nutrition, especially the amount of water intake, electrolyte balance, and salt intake. (Increasing salt intake with sea salt or a full-mineral salt can often improve blood pressure in POTS cases.)
3. Performing light exercise, as tolerated, several times a week. Working with a knowledgeable practitioner regarding exercise is very important. If you are experiencing POTS symptoms, be very cautious about doing any new exercise, perhaps begin by having someone observe.
4. Taking appropriate medications to change the heart rate, block adrenalin, increase the narrowing of blood vessels, help kidneys retain sodium, or increase blood volume.
5. Wearing compression clothing which helps force blood upward.
6. Crossing the legs helps build blood pressure in the upper body, which can be beneficial for those with POTS (8).
Treating the post-viral syndrome through antivirals, antioxidants, immune-boosting medications, and nutritional supplements may be necessary. Acupuncture and massage help alleviate chest and other pains. A round of liver detoxification may be very beneficial for POTS if heavy metals or poisons are suspected.
Many people who do get POTS may need to manage the condition until it goes away naturally. In addition to following any treatments, it may be helpful for those with POTS to attempt one or more of the following:
Avoid known triggers such as particular postures, movements, breath patterns, or emotional swings and avoid them when possible.
Be cautious when transitioning from a laying or sitting position to a standing position. Strategies include simply slowing the whole process down or finding postures that can be held for a few extra moments on the way up.
Practicing breathwork and light or beginner yoga may help people gain some control over ANS responses or reduce the severity of the responses (2).
Be as physically active as possible. (This is often referred to as "reconditioning.") Go slow, but do keep activity in your routine. The idea is to condition your body to go a little longer without having an episode of fainting or triggering symptoms.
Isometric exercises, in particular, may help recondition the body to counter POTS. This type of exercise focuses on tightening one group of muscles at a time while keeping the body still. There are good, free videos online. Again, be cautious when trying any new exercise.
TCIM has been a trusted partner for many experiencing autonomic nervous system dysfunction, POTS, long COVID, and "mystery symptoms." As part of our commitment to healthy people and the principles of integrative medicine, our doctors and practitioners take the time to investigate the root causes of symptoms rather than treat symptoms. We have just the right combination of expertise, advanced blood tests, and high-tech diagnostic equipment to distinguish between long COVID-19 symptoms and POTS. If you identify with the list of symptoms above, please make an appointment. We would be honored to support your journey to abundant, enduring health.
Jonathan Vellinga, MD is an Internal Medicine practitioner with a broad interest in medicine. He graduated Summa cum laude from Weber State University in Clinical Laboratory Sciences and completed his medical degree from the Medical College of Wisconsin.
Upon graduation from medical school, he completed his Internal Medicine residency at the University of Michigan. Dr. Vellinga is board-certified with the American Board of Internal Medicine and a member of the Institute for Functional Medicine.
1. COVID-19 and POTS: Is there a link? [Internet]. Johns Hopkins Medicine. 2022. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/covid19-and-pots-is-there-a-link
2. Professional CCM. Postural Orthostatic Tachycardia Syndrome (POTS) [Internet]. Cleveland Clinic. Available from: https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-tachycardia-syndrome-pots
3. Dysautonomia international: Postural Orthostatic Tachycardia syndrome [Internet]. Available from: https://dysautonomiainternational.org/page.php?ID=30
4. Olshansky B, Cannom DS, Fedorowski A, Stewart JM, Gibbons CH, Sutton R, Shen WK, Muldowney JAS, Chung T, Feigofsky S, Nayak HM, Calkins H, Benditt DG. Postural Orthostatic Tachycardia Syndrome (POTS): A critical assessment. Progress in Cardiovascular Diseases [Internet]. Elsevier BV; 2020 Mar 31;63(3):263–270. Available from: https://doi.org/10.1016/j.pcad.2020.03.010
5. Articles [Internet]. Available from: https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/postural-orthostatic-tachycardia-syndrome-pots.html
6. Gomez-Moyano E, Rodríguez-Capitán J, Román DG, Bueno JAR, Sánchez AV, Hernández FE, Angulo GEG, Mora MJM, Thurnhofer-Hemsi K, Molina-Ramos AI, Romero-Cuevas M, Jiménez-Navarro MF, Pavón-Morón FJ. Postural orthostatic tachycardia syndrome and other related dysautonomic disorders after SARS-CoV-2 infection and after COVID-19 messenger RNA vaccination. Frontiers in Neurology [Internet]. Frontiers Media; 2023 Aug 16;14. Available from: https://doi.org/10.3389/fneur.2023.1221518
7. Safavi-Naeini P, Razavi M. Postural orthostatic tachycardia Syndrome. Texas Heart Institute Journal [Internet]. Texas Heart Institute; 2020 Feb 1;47(1):57–59. Available from: https://doi.org/10.14503/thij-19-7060
8. Postural Orthostatic Tachycardia Syndrome (POTS) [Internet]. Johns Hopkins Medicine. 2022. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/postural-orthostatic-tachycardia-syndrome-pots
9. Postural Orthostatic Tachycardia Syndrome (POTS): Evaluation and Management | British Journal of Medical Practitioners [Internet]. Available from: https://www.bjmp.org/content/postural-orthostatic-tachycardia-syndrome-pots-evaluation-and-management