Treatment Updates in Postural Tachycardia Syndrome

Abstract

Postural tachycardia syndrome is a common condition characterized by the presence of orthostatic intolerance in conjunction with excessive postural tachycardia. This review will focus on treatment updates in postural tachycardia syndrome and will include a discussion of rehabilitative, vasopressor, heart rate modulation, volume expansion, and immunomodulatory treatment strategies. A recent study added to existing literature the benefits of exercise retraining in postural tachycardia syndrome (POTS) patients who were able to successfully complete a 3-month exercise regimen. Another recent, novel study reported the benefits of respiratory retraining in POTS patients reporting breathlessness. The benefits of volume expansion in the treatment of POTS were strengthened by 2 recent studies, including a study demonstrating the value of oral rehydration salts in improving hemodynamic parameters in POTS patients and another prospective study demonstrating the value of IV saline infusions in POTS patients. A recent meta-analysis reviewed the efficacy of ivabradine in the treatment of POTS, while another systematic review and meta-analysis reviewed the benefits of metoprolol in the treatment of childhood and adolescent POTS. Also included in this review is that of a large clinical trial comparing propranolol and bisoprolol alone and with pyridostigmine, demonstrating efficacy of beta blockers and an absence of any clear additive benefit with pyridostigmine. A retrospective review of droxidopa in a large POTS cohort reported improvement in only 27% of POTS patients. Recent approaches to the pharmacologic and non-pharmacologic treatment of cognitive dysfunction and fatigue in POTS patients were reviewed. Finally, a retrospective series of the benefits of intravenous immunoglobulin in POTS suspected of being autoimmune is reviewed. The treatment of postural tachycardia syndrome is complex and nuanced, requiring a combination of lifestyle and pharmacologic treatments in most patients. This review provides treatment updates for this enigmatic condition.