POTS Symptoms and Treatments

Dr. David Saperstein reviews hallmark POTS features—orthostatic intolerance with rapid heart rate on standing, lightheadedness/presyncope, fatigue, cognitive “brain fog,” headaches/migraines, GI upset, temperature intolerance, sleep disturbance, and anxiety-like adrenergic symptoms—and notes frequent comorbidities such as hypermobility/EDS, migraine, and GI dysmotility. He outlines practical diagnosis using standing or tilt testing (HR rise ≥30 bpm in adults or ≥40 in teens within 10 minutes without orthostatic hypotension) and basic labs to exclude mimics. Management is tiered: foundational nonpharmacologic strategies (2–3 L fluids daily, liberal salt as tolerated, compression garments to the abdomen/legs, elevating the head of the bed, heat avoidance, small frequent meals, and pacing/energy management) plus a gradual, recumbent-to-upright exercise program to improve conditioning. When needed, medications are added based on phenotype—heart rate control (low-dose beta-blockers or ivabradine), volume expansion (fludrocortisone, short-term desmopressin in select cases), and vasoconstriction (midodrine); pyridostigmine and central sympatholytics (clonidine/guanfacine) may help hyperadrenergic features. He emphasizes individualized care, addressing comorbid conditions, and setting expectations for gradual improvement over months.