Over recent months, I have had several new patients on the schedule with histories that include significant fatigue, poor stamina, very low exercise tolerance, and even such severe weakness that they faint, or nearly faint. Many of these patients are younger women, ages 14 – 30. Many of these young women have “recently” been diagnosed with POTS – Postural Orthostatic Tachycardia Syndrome. POTS is a RARE condition where the autonomic nervous system simply does not work properly.
The autonomic nervous system is the “boss” of your heartbeat, breathing, blood pressure, digestion, and more. It is also part of your “fight or flight” mechanism that keeps you alert and responsive in dangerous or scary situations.
POTS is becoming a very COMMON diagnosis today, for a variety of reasons. The most common reason for many POTS diagnoses, is that mainstream providers simply don’t know why patients have these symptoms; so they label the patient with POTS. However, POTS has diagnostic criteria that has been the gold standard for decades — mainstream is completely ignoring the standard. (How ironic.)
The standards for diagnosing POTS:
Diagnostic criteria for postural orthostatic tachycardia syndrome
All of the following criteria must be met:
- Sustained heart rate increase of ≥
30 beats/min (or ≥ 40 beats/min if patient is aged 12–19 yr) within 10
minutes of upright posture. - Absence of significant orthostatic
hypotension (magnitude of blood pressure drop ≥ 20/10 mm Hg). - Very frequent symptoms of
orthostatic intolerance that are worse while upright, with rapid
improvement upon return to a supine position. Symptoms vary between
individuals, but often include lightheadedness, palpitations,
tremulousness, generalized weakness, blurred vision and fatigue. - Symptom duration ≥ 3 months.
- Absence of other conditions that could explain sinus tachycardia
I want y’all to read through that list again, carefully, and focus on the LAST sentence. In order to label a patient with a diagnosis of POTS: NO OTHER CONDITION can exist that COULD explain the fast heart rate.
Ponder that concept for a few; if a patient has any other chemical, hormonal, physical, or genetic reason for causing the elevated heart rate, the patient CANNOT be diagnosed with POTS.
Yet, that is not what we’re seeing nationwide. Various health care professionals are diagnosis POTS based on 1-2 symptoms, ALONE, without lab testing in many cases. In the presence of lab results, many providers simply look at “normal” results and claim there’s nothing wrong. When there are ABNORMAL results, many providers completely overlook the pathophysiological FOUNDATIONS of our body processes, and ALSO say, “there’s nothing wrong, so it must be POTS.”
I find it quite distressing that so many patients are being diagnosed with POTS without adequate lab testing OR adequate interpretation of lab results. Have we, as EDUCATED professionals, completely FORGOTTEN our basic anatomy & physiology concepts we learned in our educational programs???? If so, this is a TRULY sad reflection of our health care system today.
SOoooo if these symptoms are not POTS, what are they? Why are these symptoms happening to so many? The major reason is poor lab assessment. No organization or agency recommends iron and ferritin testing, EVEN when a CBC shows abnormal levels.
What is a CBC?
A CBC is a “complete blood count” that tells how many red and white blood cells are in the specimen collected. There are “normal” ranges, but normal lab ranges are drawn from HEALTHY people. UNHEALTHY people, or those with symptoms cannot depend on those result ranges. We have to learn to look at the results with a deeper understanding of the chemistry. If a patient is reporting symptoms we’ve described above, and the CBC comes back “perfect”, then we need to look elsewhere for the symptom-related blood levels.
Most CBCs do not come back “perfect”, however. Many of these blood tests will indicate low MCV and/or low MCHC. These are characteristics of red blood cells – kind of like you describing the characteristics of a motorcycle. EX: the motorcycle is loud, fast, and adventurous. Can you measure those? Maybe – but the point is: you can create an image in your head of a loud, fast & adventurous motorcycle, right? That is what MCV, MCHC & other markers on that CBC result show us. They help us understand what the red blood cell LOOKS and functions like. The MCV describes the SIZE of the red blood cell, and the MCHC tells us about the HEMOGLOBIN IN the RBC.
Do you remember from biology or A & P what hemoglobin is? Or where it comes from? Hemoglobin is produced from FERRITIN to be used in red blood cells to transport oxygen to ALL body cells. Stay with me, here….
What kinds of symptoms do you LOGICALLY conclude that patients are likely to exhibit if oxygen
is not getting to all body cells appropriately? You guessed it – the same symptoms as POTS patients report: significant fatigue, poor stamina, very low exercise tolerance, and even such severe weakness that they faint, or nearly faint.
WHY? Ferritin is the major “ingredient” in hemoglobin. When ferritin levels fall below
65 ng/mL, the body begins to undergo some mild changes, including a bit of rationing the ferritin out. This rationing of ferritin directly impacts those characteristics of red blood cells
– their color, their volume, their hemoglobin content and more, causing cardiac impacts. As ferritin falls even further, those heart symptoms worsen. Palpitations and tachycardia are directly occurring b/c there is insufficient hemoglobin on the RBCs, making the RBC unable to deliver APPROPRIATE quantities of oxygen to body cells. As the RBC’s hemoglobin falls, there is not enough hemoglobin to pick up and transport oxygen to the body cells – including CARDIAC MUSCLE. When the heart begins to notice a decline in oxygen delivery, it begins to beat harder
and faster, especially in the presence of increased activity or exercise.
SOooo, now we’re back to our original question: Are the symptoms reported by patients being ACCURATELY diagnosed as POTS? Or should further evaluation be part of the conversation?
The last item on the diagnostic criteria is: Absence of other conditions that could explain sinus tachycardia — if low ferritin causes sinus tachycardia, then POTS can NOT be diagnosed until the ferritin is significantly improved.
REFERENCES
•McCance, K.L., Huether, S.E. Pathophsiology: The biologic basis for disease in adults & children, Chapter 24; 4th edition, 2002.
https://www.jacc.org/doi/abs/10.1016/j.jacc.2010.02.043
https://link.springer.com/chapter/10.1007/978-3-030-54165-1_4
• https://pubmed.ncbi.nlm.nih.gov/28694024/
•https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086762/
•https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/
•https://pubmed.ncbi.nlm.nih.gov/30010865/
•https://suzycohen.com/articles/methylation-problems/
Elite NP Functional Nutrition Course and Functional Medicine Certification Program
•Functional Medicine University’s Functional Diagnostic Medicine Training Program. Module 1 Lesson 7.
