Introduction: The Syncope Service has been running for a decade and is the only clinic to offer beat-to-beat plethysmography in Addenbrooke’s Hospital. An increasing number of younger patients have been referred to the clinic with suspected postural orthostatic tachycardia syndrome (POTS) though the Syncope Service is not an ideal pathway. This project evaluated referrals to the service with an aim of commissioning a dedicated POTS pathway.
Methodology: The specialist Syncope Service reviewed 1,256 patients over the past 5 years (2017 – 2021). The data of 405 patients under age 50 were retrospectively analysed.
Analysis: Referrals: 43% (n=173) were referred with presyncopal symptoms or suspected POTS. The number of referrals has increased year on year. The majority of referrals came from primary care (28.6%) followed by Cardiology (19%) and the emergency department (ED; 14.3%). A total of 42 patients were found to have borderline or definite POTS. The median age was 23 years with a range of 16 to 48, and 88% were female. Presenting symptoms: Presenting orthostatic symptoms were lightheadedness or dizziness (88%), palpitations (71%), atypical chest discomfort (43%) and tremulousness (7%). Other symptoms comprised exercise intolerance (28%), chronic fatigue (21%), brain fogging (16%) and acrocyanosis (16%). Investigations: 100% of patients had a 12-lead electrocardiogram (ECG) and beat-to-beat plethysmography; 62% had an echocardiogram; 45% completed ambulatory 24-hour ECG monitoring; 12% were investigated with 24-hour ambulatory blood pressure measuring. Routine blood tests as well as cortisol, thyroid function, ferritin and plasma metanephrine were taken. Management: 45% of patients were managed with non-pharmacological measures alone; 31% required monotherapy, 17% used dual agents and 12% necessitated triple therapy. The choice of medication was not standardised but beta blocker, fludrocortisone and midodrine were the most used medications. Follow-up plans: 50% were followed up in the syncope clinic after being diagnosed with POTS.
Implications: The Syncope Service is commissioned as an urgent pathway to prevent admissions via ED for patients presenting with syncope of unknown aetiology. It is the only clinic that offers beat-to-beat plethysmography. Referrals of younger patients with suspected POTS have increased every year though not all patients with suspected POTS have syncope. There is a need for a specialised clinic both for patients with suspected POTS, and for patients with undiagnosed syncope to be seen urgently. Patients with suspected POTS do not need to be seen with the same degree of urgency and therefore, establishing two different pathways is recommended.
Discussion: POTS is becoming increasingly well known. Many patients discover this as a possible diagnosis online and there is a need to address this group of patients. The results of this project will feed into a business plan to commission a specialist POTS pathway. ❑
