Treating Patients With Postural Orthostatic Tachycardia Syndrome

Three years after the start of the pandemic, researchers now have more clinical data associated with complications related to post-SARS-CoV-2 infection, one of which is postural orthostatic tachycardia syndrome (POTS).¹ Oral health professionals should be able to identify the signs and symptoms associated with POTS and actively assess patients, particularly those who report experiencing long-COVID symptoms.²

Definition

POTS is a disorder of the autonomic nervous system that affects the circulatory system.^3,4 A chronic condition, POTS is characterized by an intolerance to orthostasis (standing upright), in which the heart rate rapidly increases to greater than 120 beats per minute or increases by 30 beats per minute for adults and by 40 beats per minute for children and teenagers.⁵

The heart rate increase is measured from a resting heart rate after standing for 10 minutes. Under normal circumstances, the autonomic nervous system regulates blood pressure for the brain regardless of the individual’s position (ie, standing, supine, or recumbent).⁶ With POTS, however, when an individual stands, the autonomic nervous system fails to regulate the blood vessels in the legs.

This failure of restriction leads to blood pooling in the lower extremities, reducing blood flow to the brain. The heart then tries to overcompensate by pumping faster, causing tachycardia.^2,7 It is important not to confuse POTS with orthostatic hypotension, a condition in which blood pressure drops upon standing.⁵

The literature notes that patients with POTS may experience a change in blood pressure in either direction, in addition to orthostatic tachycardia.⁵ Individuals with POTS experience symptoms ranging from mild to severe, with the most common presenting as dizziness or fainting upon standing. Table 1 lists additional symptoms.

Many situations can worsen the symptoms of POTS, including but not limited to: standing for long periods of time, prior to/​during menstruation, warm environments, exercise, during periods of illness, and when fluid and salt intake has been low (such as in skipping meals).

Prevalence

POTS is a term that was first coined in 1993 by Philip Low, MD, a neurologist at the Mayo Clinic.⁸ While the term is relatively new, the condition has been described in the medical literature for 160 years. POTS has been known by other names such as neurocirculatory asthenia, orthostatic tachycardia, and orthostatic intolerance.^8,9 Often, patients with POTS are misdiagnosed with chronic fatigue syndrome, anxiety, or panic disorder.^4,8

Approximately 1 to 3 million Americans have POTS and most are women (80% to 85%) between the ages of 15 and 50, with the first symptoms usually presenting during adolescence.^2,10.11 Because POTS is often misdiagnosed, the exact prevalence has not been accurately established.¹¹

Etiology

While POTS is a disorder of the autonomic nervous system, the exact cause of POTS is unknown, with a complex pathophysiology.^10,12,13 Researchers have identified subtypes of POTS, including:^3,12

• Neuropathic POTS: dysfunction of the autonomic nervous system with venous pooling of the limbs being a common manifestation
• Hyperadrenergic subtype: exaggerated cardiovascular response upon standing resulting from elevated levels of norepinephrine
• Hypovolemic POTS: extremely low blood volume

Additionally, secondary POTS is often associated with other illnesses including diabetes, Lyme disease; autoimmune disorders such as lupus or Sjögren syndrome; and viral infections.³ Individuals with a family history of POTS are at increased risk of developing the condition, suggesting a possible genetic component, although no specific gene has been identified.¹⁴

Post-COVID-19

More recently, research has shown a relationship between individuals experiencing long COVID, a condition in which patients develop chronic symptoms (eg, fatigue, brain fog, and shortness of breath) following the resolution of a SARS-CoV-2 infection and increased reports of POTS.^1,2,15

SARS-CoV-2 infection has been shown to adversely affect both the central and autonomic nervous systems.^2,15 Autopsy reports of individuals who died from COVID-19 revealed the presence of SARS-CoV-2 in the brain, brain stem, and cardiovascular and respiratory centers of the brain, likely via the olfactory system.²

Research by Kwan et al¹ has demonstrated a higher incidence of POTS reported 90 days post COVID-19 vaccination, suggesting a possible association between COVID-19 vaccines and POTS diagnosis. However, additional research is needed to further investigate this relationship. The same study also noted that the incidence of POTS reported post-SARS-CoV-2 infection was five times higher than the occurrence after COVID-19 vaccination.¹

Diagnosis

A definitive diagnosis of POTS can be challenging given its complex nature and the presence of other medical conditions that exhibit similar symptoms. Due to the association of POTS with the nervous system and symptoms related to cardiac challenges, a consultation with a neurologist and cardiologist is warranted.

Along with a thorough medical history, a range of tests is performed, including a tilt table test, in which the patient lies on a table that tilts at intervals while vitals are recorded. An electrocardiogram is used to assess the heart’s electrical activity and a 24-hour heart rate/​blood pressure monitoring devices may be recommended to record heart activity. Blood tests are performed to rule out any other systemic conditions — such as thyroid issues and kidney and liver disease — and to assess calcium and glucose levels. Skin biopsies are done to assess nerve fiber damage.^2,14,16 Other cardiac conditions, such as valve defects, must be ruled out because they can exhibit symptoms similar to POTS.

Pharmacologic Treatments

Given the complex nature of POTS and the individual differences between patients, there is no direct pharmacological approach to treating this disorder.² Cardiologists recommend patients avoid medications that can predispose them to tachycardia, such as vasodilators, diuretics, norepinephrine transport blockers, and certain classes of contraceptives.¹⁷

The focus of treatment is on addressing the patient’s symptoms and underlying phenotype.² As patients with POTS tend to have a higher sensitivity to medications, they are often prescribed the lowest therapeutic dose.^2,12

The United States Food and Drug Administration has not approved any drugs for the treatment of POTS, however, many drugs are used “off-label” to manage symptoms. Table 2 provides a list of common medications used either alone or in combination to treat POTS symptoms and its pathophysiology. Oral health professionals should be familiar with these medications including oral side effects and contraindications with anesthesia or other medications prescribed in dentistry.^2,18

Nonpharmacologic Treatments

Nonpharmacologic treatments for patients with POTS focus on lifestyle modifications, including but not limited to:

• Transitioning slowly from seated or lying positions to standing, allowing for a gradual adjustment of blood pressure.⁵
• Increasing salt and water intake to address blood volume issues.^6,18
• Consuming smaller, more frequent meals, as larger meals require more blood volume for digestion.⁷
• Wearing compression socks to aid with circulation.^6,12
• Engaging in exercise. Many patients with POTS cannot tolerate exercises that require standing, so exercises performed in seated or recumbent positions, such as rowing machines and recumbent cycling machines, are appropriate.^12,17
• Sleeping with the head elevated 4 to 6 inches higher than the foot of the bed helps retain pressure in the blood vessels of the legs.¹¹
• Seeking psychological counseling to manage stressors that may trigger symptoms.⁶

The most effective strategy for improving the quality of life for patients with POTS involves a combination of drug therapies and lifestyle modifications, including dietary changes, exercise, and psychological counseling.^3,6,9

Treatment Considerations for Dentistry

While POTS is not life-threatening, it can cause debilitating symptoms and extreme fatigue. Approximately 25% of those with POTS are unable to work, and many experience depression and even become bedridden.² The dental environment presents challenges for patients with POTS, and the oral healthcare team must be aware of these challenges to avoid potential medical emergencies, such as fainting or tachycardia. Additionally, the dental team should be sensitive to the emotional challenges that this population may face. Many individuals with POTS experience feelings of loneliness and isolation, underscoring the importance of providing psychological and emotional support (Table 3).

The first step is to obtain a thorough medical history, including a contact list of all specialists involved in the patient’s treatment and information about any prescription or over-the-counter medications the patient is taking.¹⁹ Patients presenting with a history of POTS or with POTS-like symptoms after a positive COVID history should be screened and referred to a cardiologist and/​or neurologist.²

To accommodate the physical symptoms and morning exacerbation of POTS symptoms, shorter afternoon dental appointments are preferred. Longer appointments requiring the patient to lie down for extended periods can worsen physical symptoms and increase anxiety.²⁰ Additional appointment time should be allocated for patients to adjust from a sitting or lying position to an upright position, as they are at an increased risk of syncope.^20,21

Anesthesia considerations should be carefully implemented. Blood pressure and heart rate should be assessed before delivering anesthesia and during treatment.²¹ Due to complications with the autonomic nervous system, a patient’s pain threshold may decrease.²⁰

Caution should be exercised when using anesthesia containing epinephrine, as inadequate anesthesia can lead to the production of excess endogenous epinephrine, increasing the likelihood of tachycardia and elevated blood pressure. Alternative options should be considered.^20–22 The type of anesthesia used depends on the patient’s unique circumstances and medical complications, which may require consultation with a cardiologist.

Patients should also be questioned about their heart health and whether their symptoms are directly related to POTS or another cardiac condition, such as a heart murmur or mitral valve regurgitation. In such cases, consultation with a cardiologist and prophylactic antibiotic treatment may be necessary.¹⁹

Oral Hygiene Considerations

Patients with POTS may have low blood volume and may consume a high-sodium diet or use sports drinks to raise sodium intake. High-sugar sports drinks increase the risk of dental caries, so patients should be advised to use low-sugar or sugar-free alternatives.²⁰

Additionally, certain medications used to manage POTS symptoms may increase the risk of xerostomia. Proper caries management and strategies to address xerostomia, such as in-office and at-home topical fluoride therapies, should be implemented.¹⁹ Dehydration can significantly worsen orthostatic instability, so patients should be encouraged to maintain proper hydration, aiming for at least 1 liter of fluid intake per day.¹⁹

Fatigue may lead to inadequate oral hygiene, and patients may require more frequent recare visits to address oral hygiene challenges.^20,21 Poor wound healing related to capillary fragility may affect the outcome and healing time of nonsurgical periodontal therapy.¹⁹

Conclusion

Further research is needed to enhance the preparedness of oral health professionals in managing patients with POTS. By implementing appropriate treatment strategies, oral health professionals can deliver the best possible care and achieve optimal outcomes for patients with POTS.

References

1. Kwan AC, Ebinger JE, Wei J, et al. Apparent risks of postural orthostatic tachycardia syndrome diagnoses after COVID-19 vaccination and SARS-Cov-2 Infection. Nat Cardiovasc Res. 2022;1:1187–1194.
2. Ormiston CK, Świątkiewicz I, Taub PR. Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart Rhythm. 2022;19:1880–1889.
3. Johns Hopkins Medicine. Postural Orthostatic Tachycardia Syndrome (POTS). Available at: hopkinsmedicine.o/​​g/​​health/​​conditions-and-diseases/​​postural-orthostatic-tachycardia-syndrome-pots. Accessed May 17, 2023.
4. Dysautonomia International. 10 Facts Doctors Should Know About POTS. Available at: dysautonomiainternational.org/​​page.php?ID=180. Accessed May 17, 2023.
5. Agarwal AK, Garg R, Ritch A, Sarkar P. Postural orthostatic tachycardia syndrome. Postgrad Med J. 2007;83:478–480.
6. Kakavand B. Postural orthostatic tachycardia. Available at: kidshealth.org/​​en/​​parents/​​pots.html. Accessed May 17, 2023.
7. Cleveland Clinic. Postural Orthostatic Tachycardia Syndrome (POTS). Available at: ​my.clevelandclinic.org/​​health/​​diseases/​ঐ-postural-orthostatic-tachycardia-syndrome-pots. Accessed May 17, 2023.
8. Safavi-Naeini P, Razavi M. Postural orthostatic tachycardia syndrome. Tex Heart Inst J. 2020;47:57–59.
9. Dysautonomia International. Postural Orthostatic Tachycardia Syndrome. Available at: dysautonomiainternational.org/​​page.php?ID=30. Accessed May 17, 2023.
10. National Institute of Neurological Disorders and Stroke. Postural Tachycardia Syndrome (POTS). Available at: ninds.nih.gov/​​health-information/​​disorders/​​postural-tachycardia-syndrome-pots. Accessed May 17, 2023.
11. Vernino S, Bourne KM, Stiles LE, et al. Postural orthostatic tachycardia syndrome (POTS): state of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting – Part 1. Autonomic Neuroscience. 2021;235:102828.
12. Stephenson D. Postural orthostatic tachycardia syndrome. Available at: practicalneurology.com/​articles/떔-mar-apr/​postural-orthostatic-tachycardia-syndrome. Accessed May 17, 2023.
13. Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management Review Med. 2019;285: 52–366.
14. Cedars Sinai. Postural Orthostatic Tachycardia Syndrome. Available at: cedars-sinai.org/​​health- library/​​diseases-and-conditions/​​p/​​postural-orthostatic-tachycardia-syndrome-pots.html. Accessed May 17, 2023.
15. Blitshteyn S, Whitelaw S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients. Immunol Res. 2021;69:205–211.
16. NHS. Postural Tachycardia Syndrome (POTS). Available at: nhs.uk/​​conditions/​​postural-tachycardia-syndrome/​​. Accessed May 17, 2023.
17. RaJ SR, Levine BD. Post tachycardia syndrome (POTS) diagnosis and treatment: basics and new developments. Available at: acc.org/​latest-in-cardiology/​articles/떐/葍/葥/葚/葍/​postural-tachycardia-syndrome-pots-diagnosis-and-treatment-basics-and-new-developments. Accessed May 30, 2023.
18. Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336–2342.
19. Roberts EP, Trinh K, Stegmann M. Managing postural orthostatic tachycardia syndrome and burning mouth. Decisions in Dentistry. 2022;8(5):30-33.
20. Brodeur M. Postural tachycardia syndrome (POTS) and dentistry: a guide for dentists and hygienists. Available at: dysautonomiasos.org. Accessed May 30, 2023.
21. Brooks JK, Francis LAP. Postural orthostatic tachycardia syndrome: Dental treatment considerations. J Am Dent Assoc. 2006;137:488–493.
22. Ruzieh M, Hofmann JP, Dziuba M. Surgical and dental considerations in patients with postural tachycardia syndrome. Auton Neurosci. 2018;215:119–120.

From Dimensions of Dental Hygiene. June 2023; 21(6):30-33.