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POTS What To Avoid


Ablation of the sinus node may be detrimental to POTS patients. A Mayo Clinic study reported short-term success in five of seven ablated patients with inappropriate sinus tachycardia and postural orthostatic tachycardia features (Shen, Low, Jahangir, Munger, Friedman, Osborn, Stanton, Packer, Rea & Hammill, 2001). However, long-term outcomes were disappointing in these patients. None of the patients experienced complete eradication of symptoms. A follow-up evaluation showed no vast improvement in symptoms, despite better heart rate control. A later publication states "in our laboratory, sinus node modification, total sinus node ablation, or atrioventricular nodal ablation is not recommended for patients with inappropriate sinus tachycardia who have autonomic evidence of postural orthostatic tachycardia" (Shen, 2002).

Ablations have reportedly been detrimental to some POTS patients who were misdiagnosed as having inappropriate sinus tachycardia. After the apparently successful elimination of their "sinus tachycardia", they were left with profound orthostatic hypotension (Grubb & Karas, 1999).

Alcohol enhances peripheral venous pooling, which will exacerbate hypotension (Grubb & Karas, 1999). Alcohol can also lead to a dehydrated state.

Anesthesia can be especially challenging for patients with autonomic dysfunction. When anesthesia is absolutely necessary, an arterial line should be inserted to monitor beat to beat variations in blood pressure. Heart rate should also be constantly monitored, as anesthesia can disturb cardiovascular function. Extra IV fluids are also needed. Read more

Bending up and down, as done when picking items up off of the floor, may increase symptoms. It is best to bend at the knee and squat down rather then to bend over forward at the waist.

Blowing up balloons is similar to the valsalva maneuver and can exacerbate symptoms in some patients.  

Certain Foods, such as dairy products,may increase symptoms in some patients. White sugar and other refined carbohydrates can exacerbate hypotension by causing increased dilation in the gut (Mathias, 2000). It is important to identify and avoid food triggers. Studies show that gluten sensitivity may play a role in neurological disorders (Hadjivassiliou, Gibson, Davies-Jones, Lobo, Stephenson & Milford-Ward, 1996).

Climbing stairs will make some patients feel worse. 

Dehydration is one of the worst states a POTS patient can be in. It is very important to always stay well hydrated.

Doctors who don't know much about POTS will surely leave patients feeling frustrated. Patients of inexperienced doctors may not receive expert care and may not return to optimum health. Finding an experienced physician is not only desirable, it is a necessity. Physicians who treat dysautonomia can be located on our Physician List.

Eating large meals can worsen hypotension in some individuals with dysautonomia (Mathias, 2000). This is because large meals can cause blood to pool excessively in the abdomen.

Energy Drinks, such as Red Bull, should be avoided in those with POTS. Postural tachycardia syndrome associated with a vasovagal reaction was recorded in a young volleyball player after an excess intake of Red Bull as a refreshing energy drink (Terlizzi, Rocchi, Serra, Solieri & Cortelli, 2008).

Epinephrine is used by doctors and dentists for a variety of reasons. It is commonly used in numbing shots. It is wise to avoid epinephrine as it stimulates the heart.

Exercise will make many people with dysautonomia feel worse. Strenuous, exhausting exercise should be avoided. Some patients will experience an exacerbation of symptoms after exercise that may last for a day or more, especially if they suffer from mitochondrial disease. These patients should check with a physician before starting any exercise program.

Exercise may be helpful in abating blood from pooling in the limbs. Exercise to build and strengthen the leg muscles can be especially beneficial. Exercise can help POTS patients to avoid becoming deconditioned. A deconditioned state further exacerbates symptoms of orthostatic intolerance.

Fatigue enhances peripheral venous pooling (Grubb & Karas, 1999). Those with POTS will do well to live life at their own pace. It is important that patients don't overdo it, as this will make them feel even worse. POTS will require some lifestyle modification.

Giving blood can be harmful to people with POTS. Blood pooling in the legs already diminishes the amount of blood flowing to the heart and brain. Further, some patients are hypovolemic (have low blood volume) and need every drop of blood that they have. Blood should not be donated and should only be drawn when necessary for medical reasons. 

Heat dilates blood vessels and will make POTS symptoms worse. Patients should avoid spending a lot of time outdoors on hot days. POTS patients should not take hot showers/baths or subject their bodies to saunas, hot tubs or greenhouses. Heat enhances peripheral venous pooling (Grubb & Karas, 1999).

Holding the arms up in the air can cause problems for some individuals. Holding the arms up requires the heart to work harder to counteract the effects of gravity. This is especially difficult for the heart if there is already excessive venous pooling in the lower limbs. The heart may not be able to effectively pump blood up into raised arms and tachycardia will result from its effort.

Lifting objects can aggravate the symptoms of POTS. This may be due to the increased work load on the heart, especially if blood is pooling in the legs. Pooling blood in the lower body makes less blood available for the muscles in the upper body. Also, straining, bending over, coughing and sneezing all raise cerebral spinal fluid pressure. It has been theorized that some POTS patients may experience symptoms while lifting due to changes in cerebral spinal fluid pressure. 

Many medications will affect autonomic testing results. Some medications that have been reported to significantly affect autonomic testing results include: chlorpromazine, thioridazine, tricyclic antidepressants, bupropion, mirtazepine, vanlafaxine, clonidine, alpha blockers, beta blockers, calcium channel blockers, opiates and topical capsaicin (Sandroni, 1998). Some physicians believe patients should discontinue measures at alleviating symptoms before autonomic testing. By doing so, symptoms are more likely to present during testing. This may help a physician to discern the true nature of a patient's disorder. 

Numerous over-the-counter products, such as melatonin, can negatively effect the POTS patient. Many products stimulate the heart or lower blood pressure or have diuretic effects, etc. Some products can help one person while hindering another. For example, caffeine can have the positive effect of raising blood pressure in some individuals. However, caffeine also increases the length of time that catecholamines remain active and this can be detrimental to those with a hyperadrenergic state. POTS patients should check with their doctor before taking over-the-counter products.

Over-stimulating environments can make POTS symptoms worse. A number of POTS patients report being overly sensitive to bright lights, loud noises and busy environments.

Singing has been reported to temporarily worsen symptoms in some individuals.

Some pharmacologic agents may cause or worsen orthostatic intolerance. Please check with your physician before taking prescription or over-the-counter medications.Some of themedications that physicians have identified as causing or worsening orthostatic intolerance include:

Angiotensin Converting Enzyme Inhibitors (Grubb & Karas, 1999)
Alpha Receptor Blockers (Grubb & Karas, 1999)
Calcium Channel Blockers (Grubb & Karas, 1999)
Beta Blockers (Grubb & Karas, 1999)
Phenothiazines (Grubb & Karas, 1999)
Tricyclic Antidepressants (Grubb & Karas, 1999)
Bromocriptine (Grubb & Karas, 1999)
Ethanol (Grubb & Karas, 1999)
Opiates (Grubb & Karas, 1999)
Diuretics (Grubb & Karas, 1999)
Hydralazine (Grubb & Karas, 1999)
Ganglionic Blocking Agents (Grubb & Karas, 1999)
Nitrates (Grubb & Karas, 1999)
Sildenafil Citrate (Grubb & Karas, 1999)
MAO Inhibitors (Grubb & Karas, 1999)


Stress will often aggravate the symptoms of POTS. The body is continuously adapting to stress, whether it is physical, mental or chemical. POTS patients sometimes lack the ability to correctly process stress due to malfunctioning or excessive functioning of the autonomic nervous system (ANS). Patients may also already have high levels of norepinephrine, which is a stress hormone. POTS patients need to avoid stress (when possible) and live life at their own pace.      

Specific stresses such as surgery, childbirth and trauma (such as a car accident) have preceded or worsened the development of POTS in some individuals. This is thought to occur due to a number of factors. Surgery, childbirth and trauma can result in excessive blood loss in POTS patients who may already be hypovolemic. It is important for POTS patients to be given extra fluids during these times. Some people theorize that surgery may require a positioning of the neck that can aggravate hind brain compression. While the relationship between hind brain compression and POTS is controversial, it may be wise to avoid these positions (if possible) with POTS patients. Trauma to the neck may also aggravate hind brain compression. Trauma can result in damage to the ANS and also to areas that will secondarily effect the ANS. Likewise, some believe the straining of bearing down during childbirth can aggravate hind brain compression and effect the ANS. POTS occurring as a result of the nutcracker phenomenon is also more prevalent after childbirth. Hormonal shifts have been theorized to contribute to the development or worsening of POTS symptoms after childbirth as well.

Travel by airplane is challenging for dysautonomics and may increase symptoms. Airplane cabins are pressurized to about 6,500 feet, which is high enough to cause some dysautonomia patients to hyperventilate. Hyperventilating makes a patient more likely to get symptoms of sympathetic activation (Robertson, 2002).

Those with POTS do need to know that the air in an airplane is some of the driest in the world. Flying can have dehydrating effects in normal individuals. How much more so flying might dehydrate someone with low blood volume. Everyone should be well hydrated before boarding a plane. Also, normal people sometimes have trouble with blood pooling in their legs during flights. Rarely, this can lead to the development of blood clots. Patients prone to pooling blood may want to wear compression stockings when flying. Patients may also want to request a bulkhead seat, as this will give them more room to elevate their legs. 


1. Grubb, B. P. (2002, October). The heterogeneity of symptoms related to 
  dysautonomia. Symposium conducted at the meeting of the
  National Dysautonomia Research Foundation Northwest Ohio
  Support Group. Toledo, Ohio.
2. Grubb, B. P., & Karas, B. (1999). Clinical disorders of the autonomic
  nervous system associated with orthostatic intolerance: an overview of
  classification, clinical evaluation, and management. Pacing and Clinical
  Electrophysiology, 22, 798-810. Full text:
3. Hadjivassiliou, M., Gibson, A., Davies-Jones, G. A., Lobo,  A.J.,
  Stephenson, T.J., & Milford-Ward, A. (1996). Does cryptic gluten  
  sensitivity play a part in neurological illness? Lancet, 10, 369-371.
  PMID: 8598704 [PubMed - indexed for MEDLINE]
4. Mathias, C. J. (2000, July). Other autonomic disorders. National Dysautonomia
  Research Foundation Patient conference. Minneapolis, Minnesota.
5. Robertson, D. (2002, July). Drug Therapy. National Dysautonomia
  Research Foundation Patient conference. Washington, DC.
6. Sandroni, P. (1998, November/December). Testing the autonomic nervous  
  system. In C. B. Berde, & M. C. Rowbotham (Eds.) International 
  Association for the Study of Pain: Technical Corner From IASP 
  Newsletter. Full Text
7. Shen, W. K. (2002). Modification and ablation for inappropriate sinus
  tachycardia: current status. Cardiac Electrophysiology Review.
  6(4), 349-355. PubMed
8. Shen, W. K., Low, P.A., Jahangir, A., Munger, T. M., Friedman, P. A.,
  Osborn, M. J., Stanton, M. S., Packer, D. L., Rea, R. F., Hammill, S. C.
  (2001)Is sinus node modification appropriate for inappropriate sinus
  tachycardia with features of postural orthostatic tachycardia syndrome?
  Pacing & Clinical Electrophysiology, 24(2), 217-230. PubMed
9. Terlizzi, R., Rocchi, C., Serra, M., Solieri, L., Cortelli, P. (2008). Reversible postural
  tachycardia syndrome due to inadvertent overuse of Red Bull.
  Clinical Autonomic Research, 18(4), 221-223. PubMed

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