Functional Medicine for POTS and Palpitations

What are POTS and palpitations?

Palpitations are feelings that your heart is pounding or racing. You may also feel like your heart is skipping a beat, fluttering, or beating too hard or too fast. They are not serious most of the time. But some are caused by an abnormal heart rhythm (arrhythmia), which may be more serious.^{2, 3}

Palpitations can be caused by anxiety, stress, caffeine, nicotine, fever, exercise, too much alcohol, diet pills, or cold medicines called decongestants. An abnormal heart rhythm may be caused by heart disease, a heart valve problem, an abnormal potassium level, certain medicines or an overactive thyroid. Viral infections such as the flu or COVID-19 can also raise the risk of arrhythmias.^{2, 5}

POTS is part of a group of disorders that cause orthostatic intolerance. These are symptoms that happen when you stand up and get better when you lie down. They happen because not enough blood flows back to the heart when you move from lying or sitting to standing.¹

The classic symptom of POTS is a fast heartbeat. In POTS, a person's heart rate may increase by more than 30 beats per minute or exceed 120 beats per minute within 10 minutes of standing. In adolescents (teens), the threshold for POTS is an increase of at least 40 beats per minute. The fast heartbeat usually improves when the person lies down again.¹

Anyone can get POTS, but it mainly affects people between the ages of 15 and 50, and it is more common in women than men. It often begins after a pregnancy, major surgery, puberty, trauma or a viral illness. Some people with Long COVID have developed POTS. POTS is also linked with other conditions, such as irritable bowel syndrome, ME/CFS, migraine and hypermobile Ehlers-Danlos syndrome (an inherited connective tissue disorder). Scientists still do not know exactly what causes POTS.¹

Common symptoms of POTS and palpitations

POTS symptoms often happen when you stand up. They may come and go over time. In most cases, POTS symptoms improve over time, though some may last a long time. Exercise and physical activity can be hard because of the fast heart rate, fainting or dizziness when upright.¹

Gut symptoms are among the most common complaints in people with POTS. Feeling full quickly, nausea, bloating and belly pain are very common. Meals can trigger these gut symptoms and can also make symptoms on standing worse.⁶

The gut and the heart share some of the same nerve pathways. The vagus nerve runs from the brain to the stomach. It carries messages between the brain and organs such as the heart and digestive system, and it helps control heart rate and digestion. In some people with POTS, nerve problems may affect how the gut moves food along. Research on gut symptoms in POTS is still limited, and more studies are needed. A 2018 review found no clinical trials that tested specific treatments for gut symptoms in people with POTS.^{1, 6}

Common symptoms of POTS and palpitations include:^{1, 3}

• A fast heartbeat or palpitations, often when standing up¹
• Lightheadedness, dizziness or fainting¹
• Exhaustion or fatigue, and weakness in the legs¹
• Headaches, brain fog or trouble concentrating¹
• Blurred vision or tunnel vision¹
• Chest pain or other pain, or shortness of breath¹
• Sleep problems¹
• Digestive issues, such as nausea, bloating or belly pain^{1, 6}
• Anxiety³

How POTS and palpitations are diagnosed and treated

The first step is a check by your doctor for any serious cause. If you have never had palpitations before, see your provider. Your doctor will ask about your symptoms and habits, check your pulse, and listen to your heartbeat. An electrocardiogram (EKG) records the heart's electrical activity. It is the most common test for arrhythmias. You may also wear a heart monitor, such as a Holter monitor, during your normal activities. Blood tests can check potassium, other electrolytes (minerals in body fluids) and thyroid hormone.^{2, 4, 5}

POTS can be hard to diagnose because its symptoms often look like other conditions. People may need to see specialists, such as cardiologists or neurologists. Doctors measure heart rate and blood pressure and watch how the body responds to changes in position. A common test is the tilt table test. You lie flat on a table that is tilted to a standing position while your heart rate and blood pressure are checked. A large rise in heart rate without a large drop in blood pressure strongly suggests POTS. Other lab tests may be needed to rule out other conditions.¹

Current POTS treatments focus on low blood volume and problems with blood flow. Lifestyle changes that can help include more salt and fluids, drinking water before getting up, and tight compression garments that go up to the waist. More salt and fluid is not right for everyone. In CDC guidance on upright symptoms in ME/CFS, it is not advised for people with high blood pressure, kidney failure or congestive heart failure.^{1, 7}

Some people take medicines such as fludrocortisone or midodrine, which increase blood volume and tighten blood vessels. These can give short-term relief, but researchers are still learning how well they work over the long term. For some people, beta-blockers, which slow the heart rate, may help. Research suggests that physical activity that slowly builds in intensity can improve tolerance to standing, but it is not recommended for everyone.¹

Once your doctor has checked for a serious cause, simple steps may help with palpitations. Cutting back on caffeine, nicotine and other stimulants will often reduce them. Learning to reduce stress and anxiety can also help. Most people with palpitations do not need to go to an emergency room.²

How our care fits alongside your cardiologist

Avicenna Functional Medicine does not replace your cardiologist or the treatment they prescribe. Our role is to add to your care, not to take its place.

Our visits are for palpitations or POTS symptoms that continue after a heart evaluation. New or severe heart symptoms need prompt medical care first.²

In a functional medicine visit, we look at factors that may contribute, such as gut health and nervous system regulation, alongside the care you already receive. Our aim is to understand the whole picture of your health and to support your overall wellbeing.

Gut symptoms are common in POTS, and the vagus nerve helps control both heart rate and digestion. But research on this is still early.^{1, 6}

Please do not stop or change any prescribed medication without talking to the doctor who prescribed it. Some medicines may cause or worsen POTS symptoms, so people with POTS should talk with a doctor before starting or stopping any medicine. Decongestants and diet pills can also cause palpitations.^{1, 2}

What to expect at Avicenna

All visits are by telehealth, for patients located in Florida and Texas. We are a cash-pay practice, and we accept HSA and FSA. Care usually follows these steps:

• A free, 30-minute discovery call to talk about your health and whether our approach is a good fit for you
• A full intake visit with our health coach, under clinician supervision, covering your history, symptoms, current treatment and goals
• Testing chosen for you, where it is likely to be useful
• A personalized plan, with follow-up visits to review how you are doing and adjust the plan as needed

When to get urgent care

Contact your doctor right away if you have new or different palpitations, or if you often feel extra heartbeats (more than 6 per minute or coming in groups of 3 or more). Also contact them right away if your pulse is more than 100 beats per minute without exercise, anxiety or fever, or if you have heart disease or risk factors for it, such as high cholesterol, diabetes or high blood pressure.²

Call 911 or your local emergency number if palpitations come with loss of consciousness, chest pain, shortness of breath, unusual sweating, or dizziness or lightheadedness.²

Telehealth visits with our team are not for emergencies. Call 911 right away if you have warning signs of a medical emergency, such as:⁸

• Chest pain or pressure that lasts two minutes or more⁸
• Trouble breathing or shortness of breath⁸
• Sudden confusion, unusual behavior or trouble waking up⁸
• Fainting or passing out⁸
• Sudden dizziness, weakness or changes in vision⁸
• Being unable to speak⁸
• Severe belly pain, or sudden severe pain anywhere in the body⁸
• Coughing up or vomiting blood⁸
• Thoughts of suicide or of harming someone else (you can also call or text 988)⁸