Postural Tachycardia Syndrome (POTS)

Phillip A. Low, M.D.; Paola Sandroni, M.D., Ph.D.; Michael Joyner, M.D.; Win-Kuang Shen, M.D.


J Cardiovasc Electrophysiol. 2009;20(3):352-358. 

In This Article

Clinical Features

The age of presentation is most commonly between 15 and 50 years.[9,10] Most patients that we have evaluated have had the symptoms for about one year. The orthostatic symptoms consist of symptoms of reduced cerebral perfusion coupled with those of sympathetic activation. The most common symptoms are lightheadedness, palpitations, symptoms of presyncope, tremulousness, and weakness or heaviness (especially of the legs). These symptoms are commonly exacerbated by heat and exercise (Table 1). Other common symptoms are shortness of breath and chest pain.[11] The symptoms these patients experience differ from those of patients with orthostatic hypotension in that there are significant symptoms of sympathetic activation.[12] There may be an overrepresentation of migraine, sleep disorders, and fatigue, and fibromyalgia is sometimes associated.[1] There is a clear overrepresentation of women.[11] We have found a consistent female:male ratio of 5:1.

Early studies suggested that approximately one-half of patients have an antecedent presumed viral illness,[1,13] although recent experience suggests that this is less common. Another feature of POTS is the cyclical nature of the symptoms. Some females will have marked deterioration of their symptoms at certain stages of their menstrual cycle associated with significant weight and fluid changes. Typically, these patients have large fluctuations in their weights, sometimes up to 5 pounds. Others have cycles of several days of intense orthostatic intolerance followed by a similar period when their symptoms are less. Some patients have episodic symptoms at rest associated with changes in BP and HR that are unrelated to arrhythmias. The HR alterations are typically a sinus tachycardia, although a bradycardia can occur.[14] Fatigue can be a problem during these episodes. Some describe periods when they have trouble retaining fluid, in spite of heavy intake. Studies of fluid balance and antidiuretic hormone levels are not well documented. Orthostatic intolerance with low BP requiring repeat visits to the emergency room for intravenous saline infusions is uncommon but by no means rare.

Fatigue is commonly present.[11] Patients complain of poor exercise tolerance with physiological features including reduced stroke volume and reflex tachycardia typical of subjects who are deconditioned, such as in persons who have had prolonged bed rest.[15] Coupled with the poor exercise tolerance, an excessively long recovery cycle following exercise is often described. Additionally, patients typically note that they have low energy, even at rest. The sense of fatigue will sometimes occur in cycles and may last days or even weeks and then lift.

Clinical examination reveals an excessive HR increment. Pulse pressure may be excessively reduced and there is marked beat–to-beat variability of both pulse pressure and HR. One clinical correlate is the difficulty in palpating a radial pulse with continued standing or with the performance of a Valsalva maneuver (Flack sign). Another clinical sign is the development of acral coldness. With continued standing, there may be venous prominence resulting in a blueness and even swelling of the feet.[7]


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