POTS Part II: Treatment

Previously, we gave an overview on POTS and the diagnosis of POTS. Now, we want to answer the question - How are POTS and orthostatic intolerance treated?

Although there are many strategies that can be utilized to help patients with POTS and orthostatic intolerance, I would like to highlight the one that confers the most benefit but is also the treatment typically not stressed enough. Perhaps this is because it is not easy to implement.

I am referring to EXERCISE! Think of this as the medication that you cannot live without. For patients with autonomic dysfunction, exercise is crucial to re-establish and to maintain proper ANS function.  Exercise should include about 45 minutes aerobic activity at least 5 days/week, as well as at least 2 days of resistance training focused on the core and lower extremities. The aerobic portion should include a 5-minute warm up and cool down, with moderate to high intensity exertion in between. Exertion level is subjective and should not be gauged by heart rate monitoring. It is not recommended that patients wear any form of heart rate monitoring device (i.e., AppleWatch) because the heart rate is not reliable in autonomic dysfunction and only induces anxiety. If the patient has severe orthostatic intolerance, it is recommended to start with recumbent exercise such as recumbent bike, rowing, or swimming. The goal is ultimately to progress to upright exercise (elliptical, treadmill, etc.).  It may take up to 3-6 months to work up to this, and the process is not easy. Although many patients with autonomic dysfunction symptoms report issues with exercise intolerance, most of these patients, with a lot reassurance, can complete an exercise stress test in the exercise lab. It turns that many patients avoid exercise due to the fear of getting symptoms and the fear that they may be harming themselves. For patients with HSD/hEDS, it is also important to work with your physical and occupational therapists to make sure you are protecting your joints with whichever exercise modality you choose.

There are other treatment modalities that can help with autonomic dysfunction, but none of them will work well long-term without exercise. Think of these treatments as a bridge to help you tolerate exercise better. To help more blood return to the heart, we recommend things like compression garments, adequate hydration, and plenty of salt. To help reduce spikes of adrenaline and other stress hormones, we recommend things like meditation, yoga, and deep breathing, as well as other cognitive behavioral techniques. Medications are usually not necessary, but for patients with disabling symptoms who are not getting better, there are several options that can be considered.

Living with POTS? See the video: https://newsnetwork.mayoclinic.org/discussion/living-with-pots/

Author: Daniel Dudenkov, MD