Postural orthostatic tachycardia syndrome (PoTS) is a condition characterized by an abnormally large increase in heart rate when standing up. This results in symptoms like dizziness, fainting and heart palpitations. PoTS is estimated to impact between 1 to 3 million Americans, and is most commonly diagnosed in women between the ages of 15 to 50. Due to the complex nature of PoTS symptoms, it is crucial that patients see the right doctor to get an accurate diagnosis.
Primary Care Physician
A primary care physician (PCP) is usually the first doctor a patient with PoTS symptoms will see. PCPs are trained to evaluate a wide range of health concerns, so they can perform an initial assessment and run basic tests to look for potential causes of orthostatic intolerance. However, PCPs are generalists and may not have extensive expertise in more specialized conditions like PoTS. They can provide an initial diagnosis, but it is recommended to follow up with a PoTS specialist to confirm.
Role of PCP in PoTS Diagnosis
- Take a full medical history and listen to the patient’s symptoms
- Rule out other potential causes through physical exam and lab tests
- Check vital signs like heart rate and blood pressure lying down and standing up
- Potentially order a tilt table test
- Provide basic treatment recommendations like increasing fluid and salt intake
- Refer patient to cardiologist or electrophysiologist for definitive diagnosis
PCPs play an important role in identifying potential PoTS patients. However, patients will often need to see a specialist to confirm diagnosis and access advanced treatment options.
Cardiologist
If PoTS is suspected, a cardiologist is typically the next specialist a patient will see. Cardiologists are heart doctors who specialize in diagnosing and treating cardiovascular conditions. They are trained to evaluate heart rate and rhythm issues that occur in PoTS.
Role of Cardiologist in PoTS Diagnosis
- Review medical history and perform cardiovascular-focused physical exam
- Order advanced heart tests like EKG, echocardiogram, cardiac stress test, and cardiac monitors to assess heart structure and electrical activity
- Diagnose heart rhythm conditions and rule out heart disease
- Confirm PoTS diagnosis, often via tilt table test
- Prescribe medications to control heart rate like beta blockers
- Determine if lifestyle changes, compression garments or specialist referral needed
A cardiologist can definitively diagnose PoTS through tilt table testing and other exams. They also have specialized expertise to prescribe medications and treatments to help manage heart rate and rhythm disturbances.
Electrophysiologist
Electrophysiologists are cardiologists who specialize specifically in managing heart rhythm disorders like arrhythmias. They have advanced training in reading heart monitors and interpreting the electrical signals that control heart rate.
Role of Electrophysiologist in PoTS Diagnosis
- Analyze results of extended heart rhythm monitors like 30-day Holter monitors or implantable loop recorders
- Confirm PoTS diagnosis by identifying heart rate patterns
- Determine if arrhythmia or other heart rhythm condition also present
- Consider ablation or pacemaker if heart rate issue caused by electrical misfiring rather than PoTS
- Prescribe and manage heart rhythm medications
Electrophysiologists provide the most specialized expertise in diagnosing and characterizing heart rhythm disturbances. They can help determine if arrhythmias or other conduction issues are contributing to or complicating PoTS symptoms.
Neurologist
Since PoTS is thought to involve miscommunication between the heart and brain, a neurologist may also play a role. Neurologists specialize in conditions impacting the central nervous system.
Role of Neurologist in PoTS Diagnosis
- Evaluate patient symptoms like fatigue, headaches, brain fog, numbness/tingling and tremors
- Order neurological tests like EEGs, nerve conduction studies, and imaging tests to assess brain structure
- Rule out neurological conditions like small fiber neuropathy as potential cause of symptoms
- Consider if neurological disorder like Parkinson’s disease co-occurring with PoTS
- Prescribe medications and recommend lifestyle changes to manage neurological symptoms
A neurologist can help identify if neurological factors are contributing to PoTS, or if a separate neurological condition may be present.
Autonomic Specialist
Autonomic specialists, sometimes called dysautonomia specialists, have advanced training in conditions like PoTS that involve dysfunction of the autonomic nervous system. This system controls unconscious functions like heart rate, blood pressure, digestion and temperature regulation.
Role of Autonomic Specialist in PoTS Diagnosis
- Expertise to diagnose various forms of dysautonomia including PoTS
- Conduct autonomic testing like QSART sweat tests and gauge response to autonomic medications
- Provide comprehensive treatment plan to address autonomic dysfunction
- Prescribe specialized medications and therapies
- Coordinate multidisciplinary care with other specialists
An autonomic disorders specialist has the most specialized expertise in PoTS evaluation, diagnosis and management. They can oversee a treatment plan tailored to the individual patient’s symptoms and challenges.
Rheumatologist
In some cases, a rheumatologist may play a role in evaluating potential autoimmune or connective tissue components that could contribute to development of PoTS. Rheumatologists specialize in inflammatory and immune conditions affecting the joints and muscles.
Role of Rheumatologist in PoTS Diagnosis
- Assess for comorbid conditions like lupus, Sjögren’s syndrome, joint hypermobility syndrome
- Evaluate potential autoimmune processes that could damage autonomic nerves
- Prescribe immunosuppressant medications if autoimmune process suspected
- Provide guidance on management of comorbid rheumatologic conditions
In a subset of patients, a rheumatologist can help identify if an autoimmune or connective tissue disorder may be contributing to or compounding PoTS symptoms.
Other Specialists
Depending on an individual patient’s symptoms, other specialists could provide important insight:
- Endocrinologist – Assess for thyroid disorders, adrenal abnormalities or diabetes that may exacerbate PoTS
- Sleep specialist – Evaluate sleep apnea or sleep dysfunction that can worsen symptoms
- Psychiatrist – Diagnose and manage anxiety, depression or other mental health conditions associated with PoTS
- OT/PT – Provide rehab and deconditioning management for severe cases
A multidisciplinary approach is often needed to fully address the myriad of factors that can contribute to and exacerbate PoTS.
Diagnostic Tests for PoTS
While a thorough clinical evaluation is important, doctors will also rely on several tests to confirm a PoTS diagnosis or rule out other conditions. Common diagnostic tests include:
| Test | Purpose |
| Tilt table test | Evaluate heart rate and blood pressure response to postural change; confirms PoTS diagnosis |
| EKG | Assesses heart rhythm, rate and electrical activity |
| Holter/Event monitor | Provides 1-2 week continuous heart rhythm monitoring to capture episodes |
| Echocardiogram | Evaluates structure and function of the heart |
| Blood tests | Help rule out conditions like anemia or thyroid disorders |
| QSART sweat test | Measures autonomic nerve function by assessing sweat response |
Doctors may also order tests like a brain MRI, CT scan, or lumbar puncture to rule out neurological disorders that could mimic PoTS symptoms.
Conclusion
PoTS is a complex condition that can be challenging to diagnose definitively. PCPs play an important role in initial identification and screening. Cardiologists and especially electrophysiologists provide specialized expertise in assessing and confirming heart rate abnormalities seen in PoTS. Neurologists can evaluate potential neurological factors involved. Autonomic specialists have the most comprehensive training to diagnose and develop an integrated treatment approach for PoTS patients. Since PoTS has multisystemic manifestations, a collaborative multidisciplinary approach is key to properly identifying this often difficult to pin down syndrome.