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Understanding PoTS 7.30pm 7.2.23 @Lwnurses #LWN #LearnWithNurses Michaela Nuttall RGN MSc (make this you) Founder, Learn With Nurses Director, Smart Health Solutions Associate in Nursing, C3 Collaborating for Health Chair, Health Care Committee HEART UK Member, Nurses Working Party and Guidelines & Information Working Party, British and Irish Hypertension Society Trustee, PoTS UK @ thisismichaelaUsing Medall.orgWhat is PoTS What is PoTS? Postural orthostatic tachycardia syndrome is an abnormality of the functioning of the autonomic nervous system.Is PoTS new? Sir James Mackenzie – the Soldier’s HeartPhysiology of Upright Posture PoTS SymptomProfile 3 most Altered circulation Raised common Syncope * noradrenaline Visual greying Sweating symptoms Brain fog * Tremulousness Orthostatic headaches Nausea/Vomiting Acrocyanosis Diarrhoea Exercise intolerance Abdo pain Chest pain Sense of anxiety Lightheadedness Poor sleep Fatigue Fast palpitations Orthostatic Intolerance (OI) Syndromes of OI Symptoms of OI Diagnostic criteria: Patient must experience PoTS symptoms mostly when upright over a period of at least 3 months. A sustained increase in heart rate of greater than 30 beats per minute within 10 minutes of standing. Those aged 12-19 years require an increase of at least 40 beats per minute. These criteria may not apply to those with a low heart rate when resting. There is usually no drop in blood pressure on standing.Common 50% psychiatric Misdiagnosis - Anxiety - Panic disorder - Depression - Hypochondriasis Vasovagal syncope But you don’t look sick ?CFS/ME Active Stand Test v Tilt Table Test The Active Stand Test Head-Up Tilt Table Test The active stand test can be used to diagnose This involves lying on a table that can be PoTS. Under careful supervision, heart rate tilted to an angle of 60 to 70 degrees in a and blood pressure are measured after quiet, dimly lit, temperature-controlled room. Blood pressure and heart rate are resting lying down, then immediately upon recorded in a continuous manner. After a standing and after 2, 5 and 10 minutes. This period of 5 to 20 minutes of lying flat, the test may bring on symptoms of PoTS and table is tilted head up. some people may feel unwell or faint. Indian Pacing and Electrophysiology Journal DEFINITION (HRS 2015 consensus) 1. Frequent symptoms of PoTS on standing 2. Associated increase in HR 30 bpm (40bpm in teens) *persistent 3. No drop in BP (but PoTS and VV can co-exist)Triggers In some cases, PoTS has been reported to have developed after: • An infection such as a viral or bacterial illness. • A life stressor such as pregnancy or surgery. • A traumatic event. • Growth/puberty. • Immunisation. However, a link with these potential triggers remains unclear. Co-morbidities: • Hypermobility: EDS, HSD • CFS – up to 28% • Autoimmune – Sjogren’s, Diabetes • Mast cell activation syndrome • Post-viral: Long CovidNon-Pharmacological ManagementFluids 2-3 litres/day in adults Urine pale yellow in children Rapid water drinkingSalt +6g/per day 1 teaspoon 10 slow sodium tablets Care in hypertension renal disease heart diseaseCompressionNon-Pharmacological ManagementExercise Graduated 6 weeks to work • Pilates • Swimming • Recumbent bike • RowingDiet – little and often Low GI foodsPostural manoeuvres Krediet CTP, Wieling W. Manoeuvres to combat vasovagal syncope. Europace 2003; 5: 303.Pacing Increased symptoms Medication Remove drugs that trigger symptoms Add medication that • Improves blood volume • Narrows blood vessels • Reduces tachycardiaMedication PoTS Ca blocker Ivabradine Desmopressin Pyridostigmine Erythropoetin B blockers? OClonidine SSRIs? Midodrine Fludrocortisone (*Pacemaker) Droxidopa Vasovagal OHAvoid triggers • Time of day • Prolonged bed rest or • Rapid change of position deconditioning • Dehydration • Prolonged standing (or sitting) • Environmental heat • Stimulants • Alcohol • Large heavy meals • Exercise or physical exertion. • Menstrual periodswww.potsuk. org In Summary •PoTS is debilitating for most people •PoTS is not rare •Impact of COVID