Management of Postural Orthostatic Tachycardia Syndrome through Acupuncture and Chinese Herbs

Postural orthostatic tachycardia syndrome (POTS) is a chronic form of dysautonomia characterized by an exaggerated heart rate (≥30 bpm within the initial 10 min) response to postural transition, ¹ associated with light-headedness, headaches, chest pain, shortness of breath, and brain fog. ² The pathophysiology underlying POTS is heterogeneous, encompassing excess sympathetic tone, impaired peripheral autonomic function, volume dysregulation, cardiovascular deconditioning, and autoimmune dysfunction. ³ Hyperadrenergic POTS was the most frequent subtype (75.0%), followed by hypovolemic (44.9%) and neuropathic (37.8%, 133/352) forms. ⁴ It involves sympathetic overactivity accompanied by an inflammatory process and vagal impairment, leading to excessive catecholamine plasma levels and their associated signs and symptoms. Thus, any intervention resulting in an enhancement of the parasympathetic modulation and/or a decrease of the cardiovascular sympathetic modulation and systemic inflammation might diminish symptom intensity. ⁵ Acupuncture is a part of Traditional Chinese Medicine (TCM), which stimulates specific brain regions in different kinds of diseases caused by an imbalance between the sympathetic and parasympathetic activities. ⁶ According to acupuncture, symptoms of POTS could be caused by the following mechanisms: The spleen transforms and transports nutrients to produce qi and blood; hence, spleen qi and heart-blood deficiency or spleen yang deficiency may impair brain nourishment, leading to dizziness. To nourish the spleen qi and heart blood, the following acupoints can be provided: H 7 (Shenmen), Ren 14 (Juque), and Ren 15 (Jiuwei) nourish heart blood and calms the mind; P 6 (Neiguan) tonifies heart-qi; BL 17 (Geshu), gathering point for blood; BL 20 (Pishu), the back transporting point for the spleen, and it tonifies spleen to produce more blood; Ren 12 (Zhongwan), ST 36 (Zusanli), SP 6 (Sanyinjiao), and SP 3 (Taibai) tonifies spleen qi and spleen blood. ⁷ The brain is the “Sea of Marrow” with respect to TCM. When deficient, there will be dizziness, tinnitus, blurred vision, and fatigue, which are triggered in POTS. To stimulate the brain, it is necessary to tonify the kidneys with K 3 (Taixi) and BL 23 (Shenshu) and the governing vessel with Du 20 (Baihui) and Du 16 (Fengfu).

Heart yin deficiency in TCM can cause palpitations and circulatory instability due to qi and blood stagnation. To nourish heart yin and calm the mind, Ren 4 (Guanyuan), H 6 (Yinxi), and K 7 (Fuliu) are used. Also, to modulate the autonomic nervous system immediately and restore homeostasis, EX-HN3 (Yintang) and GV 24 (Shenting) can be used. ⁸ Acupuncture needles can be retained for 15–30 min per session, ⁹ with 2–3 sessions per week, and the treatment frequency can be adjusted based on the severity and progression of symptoms.

Acupuncture (electrical stimulation frequency 2 or 30 Hz or manual stimulation) can reduce the elevated levels of inflammatory markers such as interleukin-6 (IL-6) and activate the vagus nerve, thereby activating the parasympathetic activity, reducing the inflammation through NF-κB inhibition and janus kinases/signal transducers and activators of transcription pathway, and sympathetic overactivity associated with POTS. ¹⁰ In previous studies, there were a few Chinese herbs that were effective in improving the symptoms of cardiovascular conditions: Andrographolide, the most potent component from the leaves of Andrographis paniculata (70 mg/day) and Salviae miltiorrhizae (80 mg/day) (Danshen or red/Chinese sage), has potent anti-inflammatory properties and improves vascular endothelial function and promotes vasodilation that may help reduce peripheral vascular resistance and improve blood pooling issues seen in POTS. ¹¹ Auricular acupressure or acupuncture at the sympathetic point, shenmen, and heart point of the ear reduces the heart rate and increases high-frequency power of heart rate variability, indicating the parasympathetic dominance. Furthermore, it significantly reduces the proinflammatory cytokines such as IL-6, TNF-alpha, and IL-10, suggesting that it might help reduce the inflammatory state associated with POTS. ¹² The details of the acupuncture points are given in Table 1. A previous study demonstrates the use of acupuncture and lifestyle changes to successfully manage POTS. ¹³ Acupuncture through vagal stimulation will be effective in increasing parasympathetic activity, reducing sympathetic overdrive, and activating the anti-inflammatory vagal-splenic pathway to improve orthostatic tolerance and reduce tachycardia. However, future clinical trials are recommended to substantiate the efficacy of acupuncture for POTS.