William T. Basco, Jr, MD, MS…. August 31, 2016
Postural Orthostatic Tachycardia Syndrome
Postural orthostatic tachycardia syndrome (POTS) occurs in approximately 1% of adolescents. Teens often develop the condition after infectious illnesses (eg, mononucleosis) or athletic injuries.
POTS is characterized by chronic symptoms, including neurologic symptoms (eg, nausea, vision change, or dizziness), and an increase in heart rate of at least 40 beats/min when standing, without an alternative diagnosis for these symptoms. Overhydration, increasing salt intake, medications, exercise, and biofeedback can ameliorate symptoms. The natural history of POTS in adults shows that the symptoms improve over time, but few data exist on adolescents.
POTS in Teens
A recent study assessed outcomes in a cohort of adolescents (aged 13-18 years; mean, 16.5 years) who were diagnosed with POTS at a single clinic from 2003 to 2010. In 2013, the teens were surveyed and asked to report on their symptom trajectory as they aged into young adulthood.
The survey was sent to 502 patients, and responses were received from 172 (response rate, 34%). A majority (84%) of the respondents were girls, and the average age at the time of the survey was 21.8 years. The average period between being evaluated for POTS and completing the survey was 5.4 years.
Of interest, 81% of respondents had attained some college or technical training compared with 41% of the US population in the same age range. Among respondents older than 23 years, 49% were college graduates—a proportion greater than that among the general US population.
At the time of POTS diagnosis, 72% of the respondents reported being prescribed a beta-blocker, and 27% of respondents were still taking these drugs. The second most common drug used to treat POTS was a selective serotonin reuptake inhibitor, prescribed for 28% of patients. When asked which treatment they believed had helped most, 48% of respondents chose excessive hydration, 45% chose physical conditioning, and 41% chose a high-salt diet. Fewer than 30% of the respondents reported that a drug was the most helpful treatment.
At the time of the survey, 71% of respondents reported being in excellent, very good, or good health, and 86% responded that their symptoms were either resolved, improved, or just intermittent. Symptoms had completely resolved in 19% of respondents, and 51.2% reported that their symptoms persisted but were milder. Whereas 15.7% of respondents reported a relapsing/remitting course of POTS, only 8.7% reported that their symptoms persisted with unchanged severity. Unfortunately, 3.5% reported persistent and more severe symptoms. Young men were more likely than young women to report complete remission (36% vs 16%).
Mean self-reported physical functioning and health assessment were lower than population means. In fact, physical health scores had the greatest correlation with overall health scores. The lowest health self-assessment scores were seen among those who reported pain, nausea, and exercise intolerance in conjunction with POTS symptoms. Among all respondents, despite improvement overall, 73% reported that they still experienced some degree of physical limitation during vigorous activity, 38% reported some effect on work or other activities, and 50% said that they accomplished less than they would like to accomplish.
These findings demonstrate that a large majority of adolescents with POTS improve over time and that persistence of physical symptoms correlates heavily with perceived health.
In the introduction to their study, Bhatia and colleagues review published data demonstrating that a multifaceted approach is often the best way to improve symptoms in patients with POTS. My anecdotal experience correlates with their finding that many patients present after an illness or injury, and prolonged inactivity often exacerbates both the real symptoms and the patient's psychological responses to them.
The take-home message from this study is to remember to offer these families hope, as confirmed by follow-up data on POTS in teens. The biggest concern for these patients is that they will never feel any better, given that they are often experiencing prolonged symptoms by the time they come to medical attention. I plan to use these findings to reinforce with families the need to take a multipronged approach. Searching for additional diagnoses is not always helpful, and rarely does one silver bullet relieve all symptoms.