Postural tachycardia syndrome (PoTS)
Postural tachycardia syndrome is a condition in which the pulse races on standing, bringing with it dizziness, weakness, palpitations and brain fog.
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Medicines commonly prescribed for Postural tachycardia syndrome (PoTS)
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 5 mgActive substance: midodrineManufacturer: Cheplapharm Arzneimittel GmbhPrescription requiredDosage form: TABLET, 100 mgActive substance: metoprololManufacturer: Casen Recordati S.L.Prescription requiredDosage form: TABLET, 100 mgActive substance: metoprololManufacturer: Aurovitas Spain, S.A.U.Prescription required
Postural tachycardia syndrome is a condition in which the pulse races on standing, bringing with it dizziness, weakness, palpitations and brain fog. Lie down and within a few minutes things ease. It is not a heart disease: the heart here is healthy and working flat out to make up for a failure in the system that should hold blood pressure steady upright. It is diagnosed mostly in young people, women especially, and years often pass before anyone names it, because the symptoms look scattered and are easily put down to anxiety.
What happens when you stand up
The moment you get to your feet, around half a litre of blood is pulled downwards into the vessels of the abdomen and legs. In a healthy person this goes unnoticed: the nervous system narrows the vessels within seconds, blood returns to the heart, blood pressure holds and the pulse rises by ten beats or so.
In postural tachycardia that narrowing works poorly. Not enough blood comes back to the heart, and the only remaining way to keep the brain supplied is to beat faster. The pulse climbs by thirty, forty, sometimes sixty beats. Blood pressure usually does not fall — and that is the key difference from orthostatic hypotension, where it drops away.
The poor vessel response has different origins, and treatment follows from which one it is. In some people the small nerves of the autonomic system in the legs are not working properly. In others the stress hormone response is excessive, adding tremor, sweating, anxiety and surges of blood pressure. In others there is simply too little circulating blood volume. Often all of this lands on top of deconditioning after a long illness, and bed rest closes the loop quickly.
What it feels like
Some symptoms appear specifically on standing and settle once you sit or lie down:
- dizziness, greying or tunnelling of vision, the sense of the head floating off;
- strong, pounding palpitations;
- chest pain or tightness, breathlessness;
- trembling hands, sweating, waves of heat;
- fainting or coming close to it.
The rest lasts longer and is no easier: draining fatigue, poor sleep, headaches, nausea, bloating, constipation or loose stools, and hands and feet that go dusky and puffy after standing for a while — on brown and black skin this is harder to see, so look at the nails and palms. A separate and very common complaint is brain fog: losing track, groping for words, being unable to hold on to what you have just read.
Mornings are usually worst, along with hot weather, the period after meals, the first days of a period and the aftermath of an infection. No two days are alike, and that unpredictability wears people down as much as the symptoms themselves.
Why it starts
There is no single cause, only circumstances after which the condition shows itself. The commonest are:
- a previous infection; since COVID-19 postural tachycardia has been picked up considerably more often;
- prolonged bed rest, major surgery, injury;
- joint hypermobility syndrome and other connective tissue disorders, in which the vessel wall is more stretchy and narrows less well;
- pregnancy and the period after childbirth;
- myalgic encephalomyelitis and chronic fatigue syndrome;
- autoimmune conditions;
- the adolescent growth spurt — the condition often starts at this age and frequently settles over the years.
Worth listing separately is everything that does not cause the illness but reliably makes it feel worse: heat and hot showers, standing still for long periods, large meals heavy in refined carbohydrate, drinking too little, alcohol, dehydration from vomiting or diarrhoea, and a few days without moving.
What else produces the same symptoms
A fast pulse on standing is not unusual, and postural tachycardia is far from the only explanation. Before settling on this diagnosis, the following are ruled out:
- anaemia and iron deficiency — the commonest finding and the easiest to put right;
- an overactive thyroid;
- dehydration and hidden blood loss, including from the gut;
- heart rhythm disturbances, where an episode of palpitations starts and stops abruptly and has nothing to do with posture;
- side effects of medicines: diuretics, vasodilators, some antidepressants;
- adrenal insufficiency, which adds darkening of the skin, a craving for salt and weight loss to the weakness and low blood pressure;
- diabetes and its effect on the autonomic nerves;
- panic attacks and anxiety disorder, which produce a similar picture but also sit alongside postural tachycardia, so one does not rule out the other;
- eating disorders and sudden severe food restriction.
There is also a rare but important cause: a hormone-producing adrenal tumour. What raises suspicion is attacks of very high blood pressure with drenching sweats, severe headache and pallor, with no relation to standing up at all. It is for findings like this that an assessment is worth finishing rather than stopping at the first plausible answer.
How it is confirmed
The main test is simple and done in the consulting room. The person lies quietly for a few minutes while pulse and blood pressure are recorded, then stands, and the measurements are repeated at one, three, five and ten minutes. The diagnosis is considered if the pulse rises and stays up by at least thirty beats per minute in an adult, or forty in an adolescent, within those ten minutes, without the blood pressure collapsing, and if the symptoms have already lasted several months.
Alongside this, the usual investigations are:
- blood tests: full blood count, ferritin, thyroid hormones, electrolytes, glucose;
- an ECG and, where there are episodes of palpitations, a 24-hour rhythm recording;
- an echocardiogram to exclude a valve problem or other heart disease;
- 24-hour blood pressure monitoring;
- a tilt table test if the standing test has not given a clear answer;
- adrenal hormone tests where these are suspected.
Two points are worth grasping: a single pulse reading settles nothing, a run of readings over time is what counts; and a normal ECG and echocardiogram do not overturn the diagnosis, because in postural tachycardia they are expected to be normal.
What helps without medicines
This is always the starting point, and for many people it is enough.
Fluids. Aim for two to three litres a day, spread out; a glass of water drunk straight down before getting out of bed helps you through the first half hour. Salt is increased too, but not on your own initiative: with high blood pressure or kidney or heart disease it does harm, so this is the doctor's call.
Compression garments. Knee-high socks barely work, because blood pools mainly in the vessels of the abdomen and pelvis. What is needed is full-length stockings or tights, or an abdominal binder.
Manoeuvres for a wobble. If you feel yourself going, the best move is to lie down and raise your legs. If there is nowhere to lie, tense your muscles instead: cross your legs and squeeze your thighs, rise onto your toes and drop back, clench your fists, tighten your buttocks and abdomen. These squeeze blood back towards the heart within seconds.
Everyday habits. Get up in two stages — sit first, wait, then stand. Raise the head of the bed. Eat smaller meals more often, with fewer refined carbohydrates. Avoid standing still for long stretches and very hot showers.
Movement. Here lies the contradiction that confuses everyone: exertion makes you feel worse, while the lack of it makes the condition worse. The way out is to begin in positions where gravity is not in the way — swimming, rowing machines, a recumbent exercise bike, exercises lying down. It is worth working the leg and abdominal muscles in particular, since they are what pushes blood upwards. Upright exercise is added gradually, over months, and this is the most dependable part of the whole treatment.
When medicines are needed
If the measures above are not enough, a doctor adds drug treatment. There is no universal regimen: it is worked out by trial, sometimes several drugs or combinations are tried, and that is normal. The groups mostly used are:
- drugs that slow the pulse — beta blockers at low doses, and a medicine that slows the heart's own pacemaker without lowering blood pressure;
- a mineralocorticoid that holds on to salt and water and so increases blood volume; this is the one sometimes described simply as "a steroid", although it does something quite different from the anti-inflammatory hormones;
- vasoconstrictors that raise vessel tone in the upright position;
- drugs acting on signal transmission in the autonomic nerves;
- antidepressants of the selective serotonin reuptake inhibitor group, used both for accompanying anxiety and for their effect on vascular tone.
None of these is specifically licensed for this diagnosis in every country, so they are prescribed with caveats and under supervision, with the dose built up slowly. Changing drugs or doses on your own is unwise: some of them rebound if stopped abruptly.
When to seek help urgently
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine that is 112) if:
- the faint happened during physical exertion or while lying down;
- the faint came without any warning and the person was injured;
- chest pain is crushing and spreads to the arm, jaw or back;
- breathlessness at rest is worsening rapidly;
- palpitations come with confusion.
Fainting on exertion or while lying flat is not typical of postural tachycardia and points more towards a rhythm disturbance or heart disease, so it is never put down to PoTS without investigation. The same applies if there have been sudden deaths at a young age in the family — always tell the doctor about that.
See a doctor the same day for black tarry stools or vomiting blood alongside a fast pulse, for marked weakness after several days of vomiting or diarrhoea, or if things have clearly worsened since starting a new medicine.
Online consultation
Postural tachycardia is one of those conditions where a careful run through the symptoms yields more than an examination. In an online appointment the doctor will sort the picture into order: what appears specifically on standing, what is there all the time, how it all began, which medicines you take and what you have already tried.
Prepare a diary covering one or two weeks: pulse and blood pressure lying down and a few minutes after standing, taken at the same time of day, how much you drink and when things get worse. A home blood pressure monitor that also reads the pulse does the job perfectly well. Bring any blood tests and ECGs you have.
The doctor will help separate postural tachycardia from anaemia, thyroid disease and rhythm disturbances, suggest which investigations to start with, go through the fluid and compression plan, map out a route back to exercise and explain when it is worth seeing a cardiologist or neurologist in person.
This material is for information only and does not replace medical advice.
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