This post focuses on some of the non-medicine treatments of Postural Tachycardia Syndrome (POTS) and why they are effective.
When we stand, gravity pulls blood down, away from the heart. Since blood must return to the heart in order for it to be pumped back out to the brain and other organs, our bodies have several ways of protecting us from the effects of gravity. For example, the muscles of the belly, thighs, and legs squeeze when we stand, compressing blood vessels and pushing blood up to the heart. Every time we take a step, the pumping of the leg muscles also pushes blood towards the heart.
Patients with POTS cannot fully protect themselves from the effects of gravity. When they stand, blood “pools” in the blood vessels of the abdomen, pelvis, and legs. Blood pooling means that larger volumes of blood remain in those vessels, so less blood returns to the heart. Since less blood returns to the heart, less blood is pumped out, causing POTS symptoms. The heart rate also increases (postural tachycardia) to keep up with the body’s blood-flow needs. Thus, POTS is not a heart problem; it’s a problem of blood vessels, blood volume, and gravity.
Fluid and salt: Fluid, salt, and exercise (see below) are the cornerstones of POTS therapy. Good daily hydration with added salt intake increases blood volume. The increase in blood volume allows for more blood to return to the heart even though blood pools below the heart with standing. Adolescents should drink at least 3 liters of water (3 quarts) and take in at least 8 grams of salt (sodium chloride) daily (1.5 teaspoons).¹ This is a lot of salt. Salt tablets and salty snacks between meals can be helpful (possibly salted nuts, if not allergic).
Exercise: There is a link between POTS and poor exercise tolerance. When people are not able to exercise regularly, they develop exercise deconditioning, which means that their bodies cannot tolerate prolonged or intense physical activity. Since patients with POTS have symptoms when they stand, some patients avoid daily activities. Unfortunately, this can lead to a vicious cycle where less activity causes worsening of POTS symptoms which, in turn, leads to less exercise, eventually causing exercise deconditioning. The decrease in exercise can also have a negative effect on sleep quality, mood, and stress levels. How is this cycle broken? Start exercising. Your healthcare provider can help you develop an exercise plan.
Compression stockings: Just as muscle squeezing of the belly, thighs, and legs pumps blood up to the heart when we stand, compression stockings (waist-high, 20-30 mmHg) help to squeeze those blood vessels, providing added support and decreasing symptoms while standing.² Symptoms can worsen when compression stockings are taken off, so they should only be used during periods of prolonged standing or activity.
Stress and mood: Some patients with POTS report high levels of stress and irritability. Features of anxiety, panic, and depression are also common. It is important that you tell your healthcare provider about how you feel so that assessments can be done and treatments offered. Good sleep quality and daily exercise can improve mood, leading to better overall quality of life.
Some confusion exists about the possible links between anxiety, panic, and POTS. The next post will discuss recent research that shows how POTS symptoms differ from panic attacks.
¹ Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC; Pediatric Writing Group of the American Autonomic Society. Pediatric Disorders of Orthostatic Intolerance. Pediatrics. 2018;141: doi: 10.1542/peds.2017-1673
² Heyer GL. Abdominal and lower-extremity compression decreases symptoms of postural tachycardia syndrome in youth during tilt table testing. J Pediatr. 2014;165:395-397.