POTS, or Postural Orthostatic Tachycardia Syndrome, is an autonomic dysfunction involving the complex series of events that occur between the blood pressure and the heart rate—specifically the equilibrium of the two—as a person sits or stands. Usually, the autonomic nervous system (ANS) maintains steady blood pressure for the brain regardless of the body’s position, so when a person shifts position, the ANS alerts blood vessels in the lower body to tighten and push the appropriate blood flow to the brain. In a patient with POTS, that ANS mechanism isn’t working properly, and the person—who already likely has low blood pressure—experiences dramatic fluctuations in heart rate and blood pressure when standing or sitting up, as well as an increase in heart rate. The result is a range of symptoms including palpitations, dizziness, brain fog, and fatigue.
While millions of people experience this phenomenon, POTS itself as a diagnosis is fairly recent. Five to ten years ago, says Dr. Marcus Smith, an interventional cardiologist at CardioVascular Health Clinic, POTS was virtually unheard of.
According to Dr. Smith, a large part of the problem was a lack of understanding in the medical community regarding the condition, coupled with the ambiguity of POTS symptoms. The symptoms that characterize POTS—including nausea, shaking, cold or painful extremities, blurred vision, and fainting—are common to many other conditions, making it difficult to diagnose.
“In previous years,” says Dr. Smith, “people coming in with these symptoms were told it was stress and anxiety, a problem between the ears and not a true medical condition.”
He believes this approach was exacerbated because of the primary type of patients seeking treatment—young healthy females, who were already in a marginalized part of the medical world and exhibited no risk factors, pre-existing conditions, or comorbidities.
“We typically only think of health ailments affecting old people, sick people. But these [POTS patients] were young, healthy people who look healthy and act healthy; we just weren’t putting the pieces together.”
Now, Dr. Smith says he is seeing 10-20 POTS patients a week, most of them young healthy women in their 20s coming in on walkers, complaining of passing out at least once a day. One of his patients in particular, Ashley, was desperate for answers.
“For years, other neurologists had been trying to explain my condition to me, but didn’t seem to have the knowledge or ability to do it,” Ashley says. “They tried to scare me, throw medication at me, and send me on my way.”
“[These patients] are experiencing something very debilitating and frightening,” Dr. Smith says, “and being told it’s just stress and anxiety.”
So what’s to account for the uptick in POTS patients?
Dr. Smith cites two major reasons: a collaborative, multi-disciplinary approach to diagnosis and COVID-19.
According to Dr. Smith, the POTS diagnosis was a conclusion he and the rest of the staff at CardioVascular Health Clinic stumbled upon almost by accident. Part of CHC’s unique approach to care is having specialists from multiple medical disciplines working together under one roof. The team, which includes interventional cardiologists, vascular surgeons, and interventional radiologists, sits down regularly to discuss patients and trends. Having the depth of expertise across several service lines is helpful, says Dr. Smith, giving the physicians an opportunity to look deeper into cases, beyond the symptoms on the surface.
It was in this multifaceted arena that the CHC staff experienced the proverbial “Aha!” moment regarding POTS and their patients.
“We were sitting down and talking through our patient cases, and one doctor would recognize symptoms in another physician’s patient similar to those he just saw in one of his own,” explains Dr. Smith.
While there are no direct links between specific concurrent issues or comorbidities and POTS, Dr. Smith and the other physicians at CHC did notice a connection between POTS and pelvic congestion syndrome in particular. In pelvic congestion syndrome, the complex network of pelvic veins does not properly drain the pelvic or abdominal regions. The veins become inflamed and cannot return blood to the heart efficiently, resulting in an obstruction in the veins and symptoms like painful periods. When the obstruction can be removed or alleviated, blood flow back to the heart is restored, which can, in turn, help reduce the effects of POTS.
As the team began to coordinate efforts and look at cases more holistically, they started seeing more and more indications that POTS could possibly account for many of the ailments patients were coming to them with. “When we began to look at it from a POTS perspective and began treating both sets of patients with the same approach, those individuals began to make significant gains in their quality of life.”
For Dr. Smith, it’s clear: “If we didn’t have the environment we have, we would never have made that connection. It’s a huge advantage to the patients and to us as physicians.”
Because POTS is preceded by a viral infection in nearly 50% of cases, Dr. Smith believes the second contributing factor is the rise in COVID cases. Whereas mononucleosis or the flu may have been the predominant viral infections pre-pandemic, Dr. Smith is now seeing more COVID-generated POTS in younger patients. He references a recent American Heart Association article discussing the rise in COVID-related POTS and its increasing effect on younger people, which you can find here.
“COVID has been putting things into motion that have resulted in POTS getting worse and being more frequently diagnosed.”
Because POTS is a relatively new diagnosis, much of what is known about it is anecdotal. Without extensive research, many physicians are having to embrace an approach of trial and error. What is known, however, is that most symptoms are generated by periodic drops in blood pressure and pooling blood in the vessels, such as from standing all day or sitting for long periods of time. This means that maintaining stable blood pressure can help most patients avoid the worst effects.
Treatment for POTS is heavily focused on lifestyle modifications, with an emphasis on behaviors like diligent hydration to increase intravascular volume. Compression stockings and core strength exercises can help prevent blood from pooling, while sodium chloride pills (more commonly referred to as salt pills) can help retain fluid and increase blood pressure.
While some medications could potentially be used to treat POTS, there is no documentation or FDA approval to use them for that purpose yet, so they can be difficult to obtain through insurance. Lifestyle modifications continue to be the primary and preferred approach to treating POTS.
Though POTS has not been linked to long-term negative side effects, it can impact an individual’s current lifestyle and quality of life. However, Dr. Smith emphasizes that POTS is manageable, especially with lifestyle changes, and that, for many patients, symptoms improve or even disappear over time. He attributes this to natural changes in cardiovascular function and increased blood pressure as we age.
Dr. Smith believes POTS awareness for both physicians and patients is crucial to providing effective, quality care.
“These men and women [seeking treatment] may have been suffering for 20 years and feel no one is listening to them. When they find someone who can give them answers, they feel like they’ve really found something life-changing,” explains Dr. Smith.
Ashley, the patient who had found no relief after years visiting other specialists, completely agrees. “Dr. Smith was kind and knowledgeable, but most importantly, he listened when nobody else would. He and the other doctors [at CHC] had a complete understanding of my condition, my concerns, and my pain, and explained everything to me. It all just made sense.”
And for Ashley, the answers she needed couldn’t have come at a better time. “I’m getting married next summer,” she says, “and now I’ll be able to actually walk down the aisle.”
Dr. Smith has also noticed that many of his patients are much more informed than those in years past, having researched their ailments, read about their symptoms, and explored websites and chat groups that have provided more information and directed them to CHC.
“They come to me with good questions. I have to make sure I have the right answers,” he says. “That’s allowed me to grow in this aspect of my practice because when I can help someone successfully navigate [POTS], they can go out and share that with someone else who may need us.”
His message to men and women who may be suffering in silence?
“Don’t be ashamed of symptoms you’re having,” he urges, “because there is never a symptom that’s too small, and now, your symptoms are identifiable. Listen to your body.”
He recommends that people know what their blood pressure is—a systolic reading of 90 or below is considered at risk for POTS—and be cognizant of situations that trigger symptoms, such as hot environments, excessive standing, or stressful situations. He also urges patients to talk to their healthcare providers in-depth about what's going on. Small details may seem insignificant but could prompt your provider to ask more questions.
Dr. Smith is especially adamant about young people taking control of their health.
“Many people don’t look at health-related problems until they’re older, but ailments can affect even young people. Health is an evolving thing, and you can never be too young to look at your blood pressure or evaluate your diet.”
CardioVascular Health Clinic is uniquely positioned to treat the growing concern of POTS. Dr. Smith points specifically to the clinic’s comprehensive facilities and multi-disciplinary infrastructure. Fully equipped to treat a broad range of cardiovascular conditions, CHC is already resourced with the testing and diagnostic equipment necessary to identify and treat POTS, including extensive vein testing resources and a tilt table for performing a tilt table test, which reproduces the symptoms of POTS. And, at CHC, patients can see multiple experts quickly and receive everything they need in one facility, from diagnosis to treatment and procedures.
As their experience in POTS and POTS-related symptoms continues to grow, CardioVascular Health Clinic remains at the nation’s forefront in diagnosing and treating cardiovascular diseases and conditions. The clinic is Oklahoma’s only facility fully prepared to diagnose and treat POTS, and with 11 locations across the state, they can deliver the region’s highest caliber of personalized, quality patient care.
If you are concerned that you or a loved one may be suffering from POTS, call CardioVascular Health Clinic today at 405-701-9880 to schedule your consultation. You can also use the convenient online appointment scheduler or email at [email protected]
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