Dr. Olshansky reports a relationship with Amarin, Boehringer Ingelheim, and Lundbeck. Dr. Ziffra reports no conflicts of interest for the published content.
A 24-year-old female presented to our clinic with symptomatic tachycardia. In the clinic, she was able to replicate her symptoms, which were due to tachycardia in a standing position that resolved upon sitting. The patient was then offered eight ounces (236.6 mL) of water and, after consumption of such, the standing tachycardia was no longer observed. A diagnosis of postural orthostatic tachycardia syndrome (POTS) was made. This case report discusses a novel approach to acute treatment for POTS.
Postural orthostatic tachycardia syndrome (POTS) is an orthostatic intolerance syndrome often seen in young females in which symptoms and tachycardia occur with standing. Although no treatment has yet been proven to be ideal, supine exercise and hydration may provide some benefit. We describe a case of a 24-year-old female with POTS whose standing tachycardia was eliminated after drinking eight ounces (236.6 mL) of water. The effects of water ingestion as a treatment for POTS have rarely been described.
A 24-year-old nurse with syncope and palpitations had undergone an evaluation that included loop recorder implantation and tilt-table test two years prior, with negative results. She presented to our clinic after her symptoms worsened and was noted to have multiple episodes of tachycardia recorded on her loop recorder the month before. While sitting in the clinic, she was found to be in sinus rhythm, with a heart rate of 75 beats per minute (bpm). Additionally, her resting blood pressure was 112/72 mmHg while sitting. However, during continuous monitoring via her loop recorder, within seconds of standing, sinus tachycardia (rate: 150 bpm) ensued without an appreciable drop in blood pressure
As water ingestion can help some patients with orthostatic hypotension, we thought that such might be effective in her case as well. We had her sit and drink eight ounces (236.6 mL) of water. Ten minutes later, upon standing, her heart rate remained identical to her resting heart rate. This effect was reproducible.
Acute water ingestion can elevate
POTS is a chronic, systemic orthostatic intolerance disorder characterized by a heart rate increase of at least 30 bpm (or 40 bpm in individuals aged 12–19 years) without a corresponding drop in blood pressure.
The pathophysiology of POTS is not fully understood, but several mechanisms have been considered. Patients with POTS have orthostatic intolerance due to the inability to adequately vasocontrict veins in the legs and/or splanchnic circulation. In one study, POTS patients were compared with healthy controls to investigate autonomic function and heart size in response to exercise. Results indicated that patients with POTS had, on average, 16% smaller hearts versus the controls. Exercise training increased ventricular cavity size and symptoms.
A separate study by the Mayo Clinic
Currently, there are no clinical trial– or guidelines-established treatments for POTS or class I recommendations for its therapy. Although one study has indicated that one treatment may yield better outcomes over another,
Although no drugs are currently approved by the United States Food and Drug Administration to treat POTS, fludrocortisone,
May et al.
In conclusion, we describe the use of water ingestion as an acute treatment of POTS in a 24-year-old female. In our clinic, she demonstrated a dramatic increase in her sinus rate as it nearly doubled upon standing. Her heart rate went back to her identical resting rate upon sitting. After ingestion of eight ounces (236.6 mL) of water and five minutes of rest, standing did not affect her heart rate. This phenomenon has rarely been described for POTS, and the actual mechanism remains poorly understood. Nevertheless, it should be considered a safe adjunct to treat patients with POTS. Given the difficulties inherent in treating POTS, acute water ingestion is a safe, quick, and easy intervention that can be performed in the outpatient setting. This phenomenon needs to be investigated further.
We present this case to spur discussion on the subject of water ingestion for the acute management of POTS. We additionally welcome further thoughts.
Loop recorder representative strip of a gradual increase in sinus rate.