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Postural Orthostatic Tachycardia Syndrome (POTS) - Understanding and Management

Learn about the causes, clinical features, and management of Postural Orthostatic Tachycardia Syndrome (POTS), a condition characterized by an abnormal increase in heart rate when changing posture. Explore non-pharmacologic and pharmacologic management options.

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Postural Orthostatic Tachycardia Syndrome (POTS) - Understanding and Management

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  1. IT’S ENOUGH TO MAKE YOU FAINTPOSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME Evelyn Wiener, MD University of Pennsylvania

  2. SH

  3. OBJECTIVES • Explain physiologic response to changes in posture • List proposed causes of postural orthostatic tachycardia syndrome (POTS) • Describe clinical features of POTS • Discuss management

  4. WHY DON’T WE FALL OVER WHEN WE STAND UP??

  5. BARORECEPTORS ARE THE KEY

  6. WHAT COULD GO WRONG? • Lack of fuel • Decreased intravascular volume • Mechanical failure • Decreased cardiac output • Failure to respond appropriately • Neurogenic causes • Orthostatic failure/intolerance

  7. NEUROGENIC SYNCOPE • Inhibition of vascular sympathetic tone • Neurogenic vasodepressor reactions • Vasodepressor (vasovagal) syncope • Neurocardiogenic syncope • Carotid sinus hypersensitivity • Severe pain

  8. PATHOGENESIS ?

  9. PROPOSED ETIOLOGIES • Distal denervation • Hypovolemia • Changes in venous function • Baroreflex abnormalities • Increased sympathetic activity • Genetic abnormalities • Immune mediated

  10. CLINICAL FEATURES • CEREBRAL HYPOPERFUSION • AUTONOMIC OVERACTIVITY • DYSAUTONOMIA • SUDOMOTOR SYMPTOMS • GENERALIZED COMPLAINTS

  11. Indications for head-up title-table testing 1. Unexplained recurrent syncope or single syncopal episode associated with injury (or significant risk of injury) in absence of organic heart disease 2. Unexplained recurrent syncopal episodes or single syncopal episode associated with injury (or significant risk of injury) in setting of organic heart disease after exclusion of potential cardiac cause of syncope 3. After identification of a cause of recurrent syncope in situations in which determination of an increased predisposition to neurocardiogenic syncope could alter treatment Conditions in which tilt-table testing may be useful 1. Differentiating conclusive syncope from epilepsy 2. Evaluation of recurrent near syncope or dizziness 3. Evaluation of syncope in autonomic failure syndromes 4. Exercise- or postexercise-induced syncope in absence of organic heart disease in whom exercise stress testing cannot reproduce an episode 5. Evaluation of recurrent unexplained falls Hurst's The Heart

  12. DIAGNOSTIC CRITERIA • Heart rate increase of > 30 beats/min within 10 minutes upright tilt or • Heart rate > 120 beats/min within 10 minutes upright tilt • Consistent symptoms of orthostatic intolerance • Absence of a known cause of autonomic neuropathy • Serum norepinephrine > 600 pg/mL (hyperadrenergic form)

  13. DIFFERENTIAL DIAGNOSIS • Conditions causing/exacerbating orthostatic intolerance • Medications • Autonomic orthostatic hypotension • Inappropriate sinus tachycardia • Chronic fatigue

  14. NON-PHARMACOLOGIC MANAGEMENT • Changing eating habits, diet • Changing schedule • Measures to lessen venous pooling • Physical maneuvers, tilt training • Avoid exacerbating activities/factors

  15. PHARMACOLOGIC MANAGEMENT • No medication currently approved by FDA: ALL MEDICATIONS ARE OFF-LABEL • Increase intravascular volume • Vasoconstrictors • Block increased heart rate • Treatment for autonomic disorder

  16. RESTRICTIONS?ACCOMMODATIONS? • When/how to “protect” student at risk • Living arrangements • Snacks • Excused absence • Extra time • Driving

  17. ACKNOWLEDGEMENTS • Dawn Marsh RN (Adrian College) • Laura Champion, MD (Calvin College) • Dina M. Oleksiak,MSN,CRNP (La Salle University)

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