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Postural orthostatic tachycardia syndrome

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of postural orthostatic tachycardia syndrome are prepared by our editorial team based on guidelines from the Canadian Cardiovascular Society (CCS 2020) and the European Society of Cardiology (ESC 2020).
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Screening and diagnosis

Diagnostic criteria: as per CCS 2020 guidelines, diagnose POTS based on specific hemodynamic and symptom criteria definitions in adult and adolescent patients.
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Classification and risk stratification

Classification: as per CCS 2020 guidelines, do not use pathophysiological subtyping in the initial screening and diagnosis of POTS because of the lack of tools for such characterization.
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Diagnostic investigations

History and physical examination
As per CCS 2020 guidelines:
Elicit a detailed medical history and perform physical examination in the initial assessment of patients with suspected POTS. Recognize that this approach is sufficient for most patients to establish a diagnosis and initiate treatment.
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Obtain HR and BP measurement in supine position for at least 5 minutes, and then in standing position for up to 10 minutes. Diagnose POTS if the orthostatic tachycardia is sustained for at least 2 consecutive recordings (separated by at least 1 minute) after the first minute.
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  • Laboratory tests

  • ECG

  • Echocardiography

  • Additional testing

  • Evaluation for comorbidities

Medical management

General principles
As per CCS 2020 guidelines:
Manage patients with POTS by primary care physicians for the diagnosis, appropriate exclusion of alternative diagnoses, and initial treatments.
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Ensure collaborative multidisciplinary care including physicians and allied health professionals for patients with POTS.
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  • Pharmacologic therapy

  • Intravenous fluids

Nonpharmacologic interventions

Withdrawal of offending agents: as per CCS 2020 guidelines, withdraw any medication or substance that might exacerbate orthostatic tachycardia or orthostatic symptoms as the first therapeutic step, if possible.
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  • Water and salt intake

  • Exercise programs

  • Compression garments

Therapeutic procedures

Radiofrequency modification of the sinus node: as per CCS 2020 guidelines, do not perform radiofrequency modification of the sinus node for the management of patients with POTS because of the potential to harm.
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Surgical interventions

Surgical correction of Chiari malformation: as per CCS 2020 guidelines, do not perform surgical decompression of Chiari malformation to alleviate primary symptoms of POTS.
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  • Jugular vein dilation and stenting

Specific circumstances

Adolescent patients: as per CCS 2020 guidelines, use HR increase of at least 40 bpm from the resting supine position, with a standing HR of at least 100 bpm, as the diagnostic HR increase criterion for POTS in 12-19 years old adolescent patients.
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Follow-up and surveillance

Indications for referral: as per CCS 2020 guidelines, consider referring patients to a specialty clinic for POTS in case of diagnostic uncertainty, or a poor response to nonpharmacological and initial pharmacological treatments.
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