1. POTS Postural Orthostatic Tachycardia Syndrome Lorna Busmer Nurse Practitioner Rotherham

2. Definition Increase heart rate of > 30 bpm within 10 min of standing The standing heart rate is often > 120 bpm Without hypotension Low resting heart rate Aged 12–19 years- increment of > 40 bpm (Freeman et al 2011)

3. POTS Incidence in the UK unknown Increased frequency in females Often misdiagnosis Many given anxiety diagnosis 25-50% of people with CFS may have POTS Hoad et al 2008

4. Case Study 1 Female health professional in 30s Symptoms – Fatigue – exercise intolerance – relieved by sitting down PMH – tachycardia ECG – Normal sinus rhythm 24 hour tape – Sinus Rhythm with heart rates up to 150 bpm

5. Case Study 1 Cont. 1 st Diagnosis - Anxiety and depression 2 nd diagnosis – Inappropriate sinus tachycardia (IST) Further investigations – tilt test - drop in BP on tilt after 40 minutes – autonomic function test Supine HR 90 bpm Standing HR 126 3 rd diagnosis – POTS, IST, Vasovagal syncope (VVS) Meds – Diltiazem, Sertraline

7. Case Study 2 Female health care professional - 50s Symptoms over 20 years – Dizziness (20 years hx) – Fatigue – Nausea – Diarrhoea – Headaches – Palpitations – sweating – Tremulous – collapse PMH – Recurrent musculoskeletal problems, migraine

8. Case Study 2 Cont. 1 st diagnosis – Inner ear/Balance problem 2 nd diagnosis - Benign positional vertigo, irritable bowel syndrome and anxiety 3 rd diagnosis – JHS, POTS, VVS Treatment - Fludrocortisone, midodrine, beta blockers, SSRIs

9. Symptoms CARDIOVASCULAR Lightheaded Dizziness Rapid Heart rate Palpitations Near fainting or fainting Short of breath Chest Pain GASTROINTESTINAL Nausea Diarrhoea Abdominal cramps Constipation Bloating NEUROLOGICAL Headaches Tremulous MUSCULAR SKELETAL Restless Leg syndrome Myofascial pain Neuropathic pain GENERAL Fatigue Tiredness Weakness Exercise intolerance OTHER Excess Sweating Loss of sweating Bladder problems Sleep disturbance

11. Onset Sudden or gradual After – Virus/febrile illness – Trauma – Pregnancy – Surgery

12. Severity Mild, moderate, severe 25% of patients may be unable to work and be wheel chair dependant Disability can be equivalent to that found in heart failure (Benrud-Larson et al 2002)

13. Autonomic Nervous System

14. Disorders of the ANS Reflex Syncope Autonomic Failure POTS

15. Primary Partial Dysautonomia DevelopmentalHypovolemiaHyperadrenergic Secondary JHS Other Deconditioning

16. Overlapping Syndromes IST CSFPOTS

17. Recognition in primary care Good history Stand test Acrocyanosis Secondary causes Refer - cardiologist

18. Investigations

19. Stand test / Tilt Table Test Bloods – FBC, Ferritin, UE, LFT, TFT Bloods - Lying and standing Noradrenaline Urinary Catecolamines (Pheochromocytoma) Urinary sodium ECG/ 24 hour monitoring Echo

20. Treatment

21. Treatment – Non pharmacological Fluids Salt (except in H.Pots) Compression stockings Counter manoeuvres Psychological support and.......

22. Exercise

23. Pharmacological Trial and error Tiny doses Lack of research Off licence

24. Pharmacological Fludrocortisone Midodrine Ivabradine Beta Blockers- Propranolol, Bisoprolol SSRI/SNRI – Sertraline, Duloxetine Clonidine Octreotide

25. Psychological Support

27. Working together with individuals, families and medical professionals to offer information and support on syncope, reflex anoxic seizures and POTS www.stars.org.uk www.stars-international.org info@stars.org.uk Helpline: 01789 450 564