I'm a 20 year old female and have had orthostatic hypotension for years. I've read a lot about orthostatic hypotension, and everywhere I've looked says that it causes a decrease in blood pressure upon standing, but also that the persons pulse/heart rate stays the same.
What I'm confused about is that my blood pressure drops somewhat significantly (from about 115/75 to 90/60) and it causes the typical symptoms of orthostatic hypotension, but my heart rate also increases about 30bpm. I'm confused because I've read a little bit about POTS and all that is mentioned is the fast heart rate upon standing. But when I stand up, I have both: increased heart rate AND decreased blood pressure.
Could someone help me understand this?
The diagnostic criteria for POTS include both an increase in heart rate of at least 30 bpm or to at least 120 bpm overall from supine to standing (or upright tilt in a head up tilt table test) as well as symptoms such as lightheadedness, dizziness, fatigue, shortness of breath, presyncope, and/or syncope. That's not an exhaustive list of symptoms, and a patient does not need to have all symptoms to meet the diagnosis.
Some patients with POTS have an increase in blood pressure upon upright tilt or standing. Within this group, some will have an initial increase in blood pressure but after some period of time may experience a sudden drop in blood pressure such as in neurocardiogenic syncope. Others will not have such a drop in blood pressure and do not experience syncope.
Some patients with POTS have no appreciable change in blood pressure upon standing or upright tilt.
Some patients with POTS initially have no change in blood pressure upon standing or upright tilt, but after some period of time may have a decrease in blood pressure and may ultimately experience neurocardiogenic syncope.
Some patients with POTS do have a drop in systolic and/or diastolic blood pressure upon upright tilt or standing, which may remain consistent or persist in falling to the point of syncope.
Definitions vary somewhat, but generally speaking "orthostatic hypotension" is defined as a drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic of at least 10 mmHg (which is sustained, not momentary). So looking at your numbers, your diastolic drop is pretty significant, thus the diagnosis of orthostatic hypotension.
Diagnostic labels in dysautonomia are far from standardized. Some doctors stick with the general label "dysautonomia," while at the other extreme other doctors diagnose every aspect of dysautonomia present in a particular case. And of course there are degrees in between, and many forms of dysautonomia have multiple equivalent terms, or terms that some doctors use interchangeably while others use them for shades of meaning.
All that being said, if you think you may have POTS in addition to OH, and your doctor has not addressed this with you, it can't hurt to ask. It may or may not change your doctor's treatment plan for you. Do you have palpitations, heat intolerance, exercise intolerance, fatigue, shortness of breath, presyncope/syncope, nausea, brain fog, tremulousness, or other POTS symptoms? Since your heart rate increase is right on the borderline for the diagnosis of POTS, it may be helpful to discuss these with your doctor as well. If you haven't read Dr. Grubb's 2008 POTS article, I recommend you take a look at that, which you can find here:
If you really want an in-depth understanding of syncope, orthostatic intolerance, POTS, and pretty much everything in between, you may want to spring for his book which is also linked to on that same page. (I linked to the amazon.com listing; you may want to try to find it elsewhere or ask your local library to secure a copy through inter-library loan.)
Feel free to let me know if you still want more clarification, and just let me know where i need to be more clear!
In regard to the lack of standardization in diagnosis. While some POTS specialists essentially allow for a disregard of what the blood pressure does during standing/tilt, as this varies from patient to patient, there are specialists who will only diagnose POTS in the absence of an appreciable drop in blood pressure or signs of autonomic neuropathy. So, in light of your orthostatic hypotension, your doctor may be in the camp that rules out a POTS diagnosis; however, the increase in heart rate and any symptoms not accounted for by OH may lead to a reconsideration of your diagnosis or consideration of further autonomic testing.
IST should be reflected by a resting heart rate >100 bpm which is not accounted for by medications or stress, etc. It may resolve while sleeping and go back up while awake.
I think we've beaten the diagnostic criteria of POTS like a dead horse, so I'll leave that be for now. :-p
To complicate matters, there are cases (albeit rarely) where I've seen POTS and IST diagnosed concurrently. I have no idea if this is a universally accepted practice, but it happens often enough. Essentially, the patient has a resting heart rate >100 bpm and then on top of that, it goes up over 30 bpm upon standing, with accompanying POTS symptoms.
That rare situation aside, the diagnostic distinction between POTS and IST is pretty critical, because some cases of IST are good candidates for catheter ablation. However, you will rarely if ever see a publication these days recommending ablation for POTS, as it has a nasty track record in POTS patients of actually worsening the symptoms. It has been noted that:
"it is sometimes difficult to differentiate between them (especially between IST and POTS, as patients with POTS frequently have persistent elevation of heart rate and patients with IST frequently have fluctuation of heart rate during orthostatic challenge)"
however, the same article does point out several symptoms that are experienced in POTS which are not characteristic of IST. I would think that were the diagnosis equivocal, the decision would be made in consideration of the patient's symptom profile.
*from: Yusuf, Shamil & A. John Camm. Deciphering the Sinus Tachycardias. Clinical Cardiology. 28, 267-76. (2005).
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