Management of POTS: Syncope

In this video Dr. Goldstein discusses ways to manage the patient with chronic orthostatic intolerance commonly seen in POTS and Syncope patients.


In this video we’ll talk about the management of POTS.

Just as the most important autonomic function test, is the, what’s the most important autonomic function test?  History.  The most important treatment of POTS or chronic orthostatic hypotension, chronic orthostatic intolerance is education.  We are going to talk about education.  What does that mean, education? We will talk about that and then about nondrug treatments, and way at the bottom here, we will get into drug treatment but that is only a small part of the management of POTS or orthostatic intolerance.  As Socrates is famous for saying, “Know thyself”.  You have to know what the symptoms are that fit with POTS and what symptoms don’t.  So, if a patient with POTS complains of Coat Hanger phenomenon, let’s say, that fits with POTS as we discussed before.  Should the person have slow upper GI transit, bloating, early satiety, nausea or vomiting that fits with POTS.  You need to know the syndromic nature of the disease and so does the patient.  Does salt help? I don’t know you have got to pay attention to it.  Each person is his or her own self and prognosis is important – people don’t die of POTS, they die of Parkinson’s disease, die of dementia and so forth.  POTS is a lousy condition, but as far as I know it doesn’t involve into a neurodegenerative disease.  In fact, a substantial minority of patients get better, it takes a long-long time, years, maybe they are coping with their condition better.  Non-drug treatment, I think about antigravity muscle training, learning whether drinking water helps, compression, like SPANX, to try to maintain the venous return to the heart, IV saline – very controversial topic, I think there are patients who benefit but there are substantial risks too. CeraLyte, it’s a rice-syrup based electrolyte solutions.  It was originally used for diarrhea of cholera and then it turned out the company was selling a lot of it in America, where there isn’t a lot of cholera, and that was because people with POTS were buying it up.  I don’t know if it works, but it might in terms of minimizing water and salt loss.  This is what SPANX look like.  Cardiac pacemaking for syncope, the key is it’s hardly ever indicated.  Drugs, they are all question marks, these are all research topics and I think beyond the scope of this.