POTS Treatment in Australia: Three Things Most Patients Are Never Told
By Reine DuBois, Integrative Naturopath and Clinical Director – The Health Lodge
If you have been diagnosed with Postural Orthostatic Tachycardia Syndrome, or you suspect it, you have probably already been told to drink more water, add salt and wear compression. That advice is correct. For a lot of people it is also not enough, and the reason is usually that nobody has worked out which version of POTS they actually have.
POTS is not one condition. It is a pattern of orthostatic intolerance with several different drivers sitting underneath it. Some people have a genuine deficit in circulating blood volume. Some have impaired nerve signalling to the blood vessels in the legs and abdomen, so blood pools when they stand. Some have an overactive sympathetic response driving the heart rate up. Many have a mix. Treatment that works beautifully for one driver can do very little for another, which is why so many patients cycle through advice that half works.
Here are three things that change the picture.
1. The ten-minute lean test tells you more than a single clinic reading
Most people are diagnosed on a heart rate taken once, sitting, in a busy consulting room. The NASA Lean Test is a standardised ten-minute version that is far more revealing, costs nothing and can be done almost anywhere. It has been shown to be a workable bedside alternative to formal tilt table testing (Bashir et al., 2021).
The principle is simple. You lie flat for ten to fifteen minutes and record a true resting blood pressure and heart rate. You then stand with your heels about 15 cm from a wall, leaning back so only your shoulder blades touch it, with your legs and arms relaxed. Leaning like this removes the muscle pump in your calves, so what gets measured is your autonomic response rather than your effort. Blood pressure and heart rate are recorded immediately and then at the end of every minute for ten minutes, along with any symptoms.
The pattern clinicians look for is a sustained heart rate rise of at least 30 beats per minute in adults, or at least 40 in people aged 12 to 19, without a significant drop in blood pressure (Sheldon et al., 2015).
**Please read this part carefully. ** Do not attempt this alone. Have someone with you, put a chair directly behind you and stop immediately if your vision greys, your hearing changes or you feel you are going to faint. Do not alter, hold or taper any prescribed medication in preparation for a test at home. Medication changes around testing are a decision for the doctor who prescribed them.
If you can get even a rough set of numbers with a companion, bring them. They tell us a great deal before you have walked through the door.
2. How you respond to supervised fluids is information, not just relief
Intravenous fluids are well established as a way of easing severe POTS symptoms. In a study of patients whose symptoms had not responded to medication, intermittent saline infusions produced meaningful relief in the large majority, and most were able to step away from them within six months as other therapies took hold (Ruzieh et al., 2017).
What interests us clinically is not only the relief. It is the shape of the response. A patient whose palpitations, dizziness, weakness and brain fog resolve dramatically within an hour of volume replacement is telling us something quite different from a patient who feels only mildly better. That observation is not a test and it does not label you. It is one useful input alongside your history, your lean test numbers and your bloods, and it helps us understand whether low circulating volume is a major part of your picture or a minor one.
This is done under medical supervision. Whether it is appropriate for you at all is a decision our doctor makes after reviewing your history and your existing cardiology and GP workup.
3. If you are constipated, that is not a side issue
This is the one that gets missed. Gastrointestinal symptoms are extremely common in POTS. In a UK hospital series of POTS patients referred to gastroenterology, bloating, constipation and abdominal pain were the dominant complaints, and a large proportion also had a hypermobility diagnosis (Nayagam et al., 2019).
The reason it matters is mechanical as much as neurological. When transit slows, stool sits in the colon longer, more water and sodium are drawn back out of it, and the stool becomes harder to move. You have just lost part of the fluid and salt you were carefully drinking to hold your blood pressure up. A loaded colon also increases pressure in the abdomen and adds to the pooling of blood in the splanchnic circulation when you stand. The gut problem and the standing problem feed each other.
It is also possible to be significantly loaded while still opening your bowels most days, which is why this often goes unrecognised.
In practice, we treat slow transit as a priority rather than something to deal with later. Improving it frequently improves orthostatic symptoms too.
Working it out properly
Understanding your drivers takes observation over days, not a single appointment. Our medical retreat at The Health Lodge is a five day residential stay for exactly this kind of work. You are here with doctors, nurses, naturopaths, osteopaths, a psychologist and a breath coach, so the vagal and deconditioning rehabilitation runs alongside the volume and gut assessment rather than being left until afterwards. Supervised lean testing, a proper constipation history and, where clinically indicated, a supervised fluid trial all happen in the same week.
Before you come, we ask for your cardiology and GP records, and our nurse completes a full intake so we know the retreat is suitable for you. You leave with a clear picture of what is driving your symptoms and a plan you can continue at home with your own practitioners.
If you would like to talk through whether this is right for you, book a discovery call with me.
Reine DuBois
Clinical Director and Integrative Naturopath, The Health Lodge
References
- Bashir, M., Ahluwalia, H., Khan, T., & Sayeed, S. I. (2021). Role of NASA 10-minute Lean Test in diagnosing postural orthostatic tachycardia syndrome: a preliminary study in young population. *Italian Journal of Medicine*, 15(1).
- Nayagam, J. S., Sagar, V. A., & Asante, M. (2019). Managing gastrointestinal manifestations in patients with PoTS: a UK DGH experience. *The British Journal of Cardiology*, 26, 101–104.
- Ruzieh, M., Baugh, A., Dasa, O., Parker, R. L., Perrault, J. T., Renno, A., Karabin, B. L., & Grubb, B. (2017). Effects of intermittent intravenous saline infusions in patients with medication-refractory postural tachycardia syndrome. *Journal of Interventional Cardiac Electrophysiology*, 48(3), 255–260.
- Sheldon, R. S., et al. (2015). Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome. *Heart Rhythm*, 12(6), e41–e63.
- Maurer, A. H. (2016). Gastrointestinal Motility, Part 2: Small-Bowel and Colon Transit. *Journal of Nuclear Medicine Technology*, 44(1), 12–18.
*This article is general information and not a substitute for individual medical advice. Do not start, stop or change any prescribed medication without speaking to your doctor.*