Dr. Yash Kathuria
Family Physician
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello,
I am a 25-year-old female. I have been diagnosed with POTS (postural orthostatic tachycardia syndrome), and a Holter monitor also picked up paroxysmal atrial flutter episodes. I have no other heart conditions; my echocardiogram, 24-hour blood pressure profile, thyroid, electrolyte, and blood count tests were normal. I have three other health conditions: ulcerative colitis, chronic migraine with aura, and hypermobility Ehlers-Danlos syndrome. I have been dealing with POTS for the past four years, and I was recently diagnosed after undergoing a tilt table test. I have experienced sudden episodes of higher heart rate, prompting me to undergo a Holter monitor test, during which some paroxysmal atrial fibrillation (AF) was detected. These AF episodes occurred once over the course of a week, lasting for fifteen minutes at night, while the rest of the week still showed sinus tachycardia and POTS. Currently, I am taking Mesalazine for ulcerative colitis. In the past, I was prescribed Sumatriptan for migraines, but I was advised to limit or discontinue its use due to the risk of atrial fibrillation and stroke. My question is, due to the increased risk of stroke associated with atrial flutter, what would you advise regarding POTS treatment? It was once suggested that I take Midodrine or Fludrocortisone for my POTS, but since they raise blood pressure, and Midodrine constricts blood vessels, would it be safe to take these with the increased stroke risk associated with AF? (I have no other increased stroke risk factors other than being a woman and not being active). POTS affects my life on a daily basis, but AF is random and not present daily. So, I am unsure what to do. I do have a cardiology appointment, but it is six months away.
Kindly help.
Hello,
I am glad you chose icliniq for your medical-related queries.
I understand your concerns regarding POTS and atrial flutter that you have been facing for some time now. Regarding the cause of palpitations, they may be precipitated by excess consumption of tea, coffee, smoking, and alcohol. Structural heart disease can also trigger palpitations, but as you mentioned, your echocardiogram is normal. POTS (postural orthostatic tachycardia syndrome) can be treated with various measures, such as increasing fluid intake, which you should do more frequently. Additionally, you can consider adding some extra salt to your diet to help maintain blood pressure and circulation. Compression stockings can also be used to prevent blood pressure from falling when standing. Regarding Fludrocortisone, you may start taking it if the above measures fail and you still experience symptoms. However, it is better to avoid Midodrine as it carries a risk of producing atrial flutter. Low-dose beta blockers like Bisoprolol or Metoprolol can be taken to manage atrial flutter.
I hope this information is helpful. Please feel free to reach out if you have any more questions.
Thank you.
Patient's Query
Hi doctor,
Thank you for your response.
I have tried beta blockers for migraines in the past, and my blood pressure became very low on them (75/44 was one reading). I assumed this might be related to my POTS and blood pooling when standing. Therefore, I am not sure if it would be safe or a good idea to try another one? Also, I forgot to mention that during the episode of atrial flutter, I had taken a Sumatriptan tablet around 1 hour beforehand due to a migraine attack. Could the Sumatriptan have been the cause of the atrial flutter? As I mentioned, my neurologist has advised me to avoid them for now until I speak to my cardiologist, but I am just wondering if that is possible?
Hi,
Welcome back to icliniq.com.
Yes, Sumatriptan can definitely cause an increase in heart rate, so it is better to avoid it. You can take Fludrocortisone; it would not cause atrial flutter and would reduce your POTS symptoms. Try compression stockings. Avoid rising rapidly from a sitting position. If you have a history of low blood pressure from beta blockers, then avoid them. Alternatively, they can be started at a low dose, like Metoprolol XL 12.5 mg.
I hope you are satisfied with my answer. For further queries, you can consult me at icliniq.
Thank you.
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Family Physician
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