POTS (Postural Orthostatic Tachycardia Syndrome)
The National Institutes of Health describe Postural Orthostatic Tachycardia Syndrome (POTS) as one of a group of disorders that have orthostatic intolerance (OI) as their primary symptom. OI describes a condition in which an excessively reduced volume of blood returns to the heart after an individual stands up from a lying down position. The primary symptom of OI is lightheadedness or fainting. In POTS, the lightheadedness or fainting is also accompanied by a rapid increase in heartbeat of more than 30 beats per minute, or a heart rate that exceeds 120 beats per minute, within 10 minutes of rising. The faintness or lightheadedness of POTS are relieved by lying down again. Anyone at any age can develop POTS, but most individuals affected (up to 80 %) are women between the ages of 15 to 50 years of age. Some women report an increase in episodes of POTS right before their menstrual periods.
POTS often begins after a pregnancy, major surgery, trauma, or a viral illness. It may make individuals unable to exercise because the activity brings on fainting spells or dizziness.
Doctors aren't sure yet what causes the reduced return of blood to the heart that occurs in OI, or why the heart begins to beat so rapidly in POTS. Current thinking is that there are several mechanisms. Some individuals have peripheral denervation (neuropathic POTS); some have symptoms that are due to sustained or parosyxmal overactivity of the sympathetic nervous system (hyperadrenergic POTS); and many individuals with POTS have significant deconditioning.
Symptoms of POTS
POTS can cause symptoms that may be mild or severe, including light-headedness, fatigue, sweating, tremor, palpitations, exercise intolerance, near syncope, recurrent syncope (fainting) when standing upright, mental clouding (“brain fog”), blurred vision, shortness of breath, early satiety (feeling of fullness), nausea, headache, chest pain, anxiety, flushing, low blood pressure (hypotension), especially after eating, back, neck, and shoulder pains, cold hands, feet, and nose. Worsening of symptoms may be brought on by eating, showering, or even mild exertion.
In refractory and severe cases, treatment may not help much, and there may be a high degree of disability.
[Reference: Abed H, Ball P, and Wang LX. “Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review.” J Geriatr Cardiol. 2012 Mar; 9(1): 61–67.]
Treatment for POTS
Treatment for POTS includes adding extra salt to the diet and keeping well-hydrated. Medications, such as fludrocortisone or midodrine, can help the symptoms of POTS by increasing the blood volume and narrowing the blood vessels. Ivabradine (a sinus node blocker) and beta blockers, like propranolol, may help some patients. Erythropoietin increases blood pressure in patients with POTS by constricting the blood vessels and increasing the number of red blood cells in the circulation. Pyridostigmine bromide, ergotamine, octreotide, ephedrine, pseudoephedrine, yohimbine, theophylline, methylphenidate methyldopa, non-steroidal anti-inflammatory drugs (NSAIDs, such as indomethacin), and some anti-depressants have all been used from time to time, with varied success. Id.
Objective Tests for POTS
In addition to a patient's self-report of symptoms associated with POTS, there are some objective tests that help to confirm the diagnosis.
In a patient with POTS, the heart rate typically increases by 30 beats per minute or more, within 10 minutes of standing or head-up tilt on a tilt-table. A patient's standing heart rate often is 120 beats per minute or more, within 10 minutes of standing or head-up tilt. [Reference: Kavi L. Am Fam Physician. 2012 Sep 1;86(5):392-394.]
These are objective abnormalities on physical examination that help confirm the diagnosis of POTS and that should be carefully documented by a treating physician.
Patients with POTS have tachycardia (rapid heart rate) that originates from the sinus node, which may be documented on an electrocardiogram (EKG), echocardiogram, or Holter monitor. A Valsalva maneuver often produces a vigorous pressor response, and an exaggerated blood pressure fall, recovery and overshoot, may be seen and should be documented by the doctor.
There are some laboratory tests that can be performed, including an upright plasma norepinephrine (after at least 5-10 minutes of standing or tilting) level, which is frequently elevated (>600 pg/ml) in POTS patients, reflecting the exaggerated neural sympathetic tone that is often present in these patients.
Disability Benefits for POTS
Whether you are applying for Social Security Disability (SSDI) benefits or for long-term disability (LTD) benefits under an employer-sponsored group plan (ERISA), working closely with a doctor that understands POTS, and with a lawyer that can work with your doctor, are extremely important to properly documenting in the medical records your condition and its disabling symptoms.
Careful documentation of symptoms, such as light-headedness, fatigue, palpitations, syncope, brain fog, and exercise intolerance, should be documented in the medical records, along with any objective testing to confirm the diagnosis. But that's not enough. The documentation in the medical records must also include a description of what specific activities you can and cannot perform (“functional impairments”) because of your symptoms.
These functional impairments should include home-based activities (e.g., making the beds, preparing meals, shopping) that you are unable to do, and job-related activities (e.g., sitting, standing, walking, lifting, carrying, concentrating, staying on task) that you are unable to do.
Because disability claims for POTS are often based on self-reported subjective symptoms from the patient to the doctor, that information must be consistent, thorough, and well-documented in the medical records.
Your disablity lawyer must work closely with your treating physician to get the proper documentation of your specific findings and impairments into the medical records. At Law Med, that's what we do.