Postural Tachycardia Syndrome A Concise and Practical Guide to Management and Associated Conditions

Part I - Introduction.- POTS – an introduction.- What is it?.- Historical background.- Clinical presentation.- Specialties where patients may be seen.- Part II - Speciality Assessment.- Cardiological and neurological considerations.- Diagnostic criteria (not just a heart rate issue).- Pathophysiology and classification.- Tests to consider, are they useful, what do they show.- Cardiological – CPET, echo, holter etc.-Neurological – MRI, nerve conduction studies.- Autonomic.- The simple active stand / tilt.- Full autonomic function tests.- Red flag symptoms.- Cardiology.- Neurology – MS, myopathy, epilepsy.- Overlap conditions (mitral valve prolapse, IST).- Associated neurological conditions.- Migraine.- Sleep disturbance.- Part III - Associated Conditions.- Rheumatology.- Overlap with hypermobility conditions.- New consensus guidance on hypermobility.- When toconsider serious hypermobility.- When to consider other inflammatory arthritides.- Overlap with fibromyalgia and CRPS.- Practical joint management including therapies.- Endocrinology.- What tests should we do to exclude an endocrine driver.- How can we recognise and treat the symptoms of reactive hypoglycaemia.- When do we need to consider referral to endocrinology.- Gastrointestinal manifestations.- Symptoms and causes.- What tests to do to exclude alternative conditions.- Simple and safe treatments that might help.- When to refer to the gastro’ clinic.- What treatment is instituted in the specialist clinic?.- Urology / Urogynaecology.- Potential symptoms.- When to consider referral?.- Investigations to consider.- Treatments.- Association with Histamine abnormalities.- Mast cell activation.- What is it?.- When does one consider it?.- What tests to do to define its presence?.- Can we treat it empirically without immunology review.- When to refer.- Audiovestibular medicine.- Recognising vertiginous contributions (migraine variant balance disorder).- When to refer and what to expect.- Part IV - Relevant Diagnostic Considerations.- Potential alternative causes.- Metabolic issues.- Lyme disease.- Chronic Fatigue syndrome.- Part V - Therapy.- Treatment.- Non-pharmacological – salt, fluid, compression.- Non-pharmacological – exercise.- Pharmacological – when and how to use it.- Midodrine.- Ivabradine.- Betablockers.- Fludrocortisone.- Octreotide.- Pyridostigmine.- Clonidine.- Others e.g. desmopressin, EPO, SSRI, IV fluid.- Assessing benefit.- Part VI - Relevant Therapeutic Associations .- Obstetrics / Gynaecology.- Are there links with endometriosis and PCOS?.- Who should be referred and when?.- Implications for pregnancy and its management.- Pelvic floor issues.- Anaesthetic management.- Anaesthetic considerations in POTS / EDS.- Respiratory medicine .- Hyperventilation is common – why and how to recognise it; why does it occur.- What clinical findings / tests can exclude other conditions.- When to refer to respiratory physio’.- What management can help hyperventilation.- When to consider respiratory medicine review.- Psychological contributors.- Functional symptoms.- Stress responses.- When to involve a psychologist / psychiatrist.- CBT and other therapies.- Part VII - Service Models.- Primary Care.- When to consider referral.- Pointers in the surgery to the diagnosis.- Tests to do first.- Challenges of referral.- Shared-care arrangements.- POTS clinics.- UK models of care KCH, NHNN, Sheffield, Newcastle, William Harvey, Royal Brompton, St Mary’s, Poole.- Can you set up your own autonomic tests and how do you do it?.- Nursing aspects.- Developing a nurse led clinic.- Nurse-led follow-up.- Patient aspects.- POTS-UK / STARS.- EDS UK / International HMSA. 

Dr Nicholas Gall qualified in 1993 from Guy’s and St Thomas’ Hospitals. He trained in General Internal Medicine and Cardiology and is a Consultant Cardiologist (electrophysiology) at King’s College Hospital and an Honorary Senior Lecturer at King’s College. He has a particular interest in loss of consciousness and autonomic conditions including PoTS: Neuro-cardiology. He has published widely, has an active PoTS research program and speaks at National and International conferences.  With Prof Kavi, he developed the PoTS masterclass  and has run the London Syncope conference since 2010. He is a Patron of PoTS-UK and medical adviser to STARS. 

Dr Lesley Kavi obtained her medical degree at Glasgow University.  She is currently working as a GP in Solihull and is Visiting Professor at Birmingham City University where she teaches on the Advanced Practice MSc. She was appointed as RCGP Syncope Clinical Champion in 2019 and developed an online open access toolkit for use by clinicians in primary care. In 2011 Lesley became a trustee of PoTS UK, the national charity that supports patients with postural tachycardia syndrome. In 2017 she took on the role of chairperson. Her special interests include PoTS, syncope and women’s health.

Dr Melvin Lobo is a Consultant Cardiovascular Physician and Director of the Bart's Blood Pressure Clinic based in the Barts Heart Centre and the William Harvey Research Institute.  He has a specialist interest in blood pressure disorders of all types, PoTS and autonomic control of the circulation. He is an accredited Clinical Hypertension Specialist of the European Society of Hypertension (ESH) and British Hypertension Society. Professor Lobo has participated in numerous clinical trials, particularly in the field of novel device therapy of hypertension. His research work has been featured on television and in the national press on numerous occasions.