Managing Postural Tachycardia Syndrome in Eating Disorder Patients

Initial Assessment and Monitoring

The American College of Cardiology recommends completing a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests to detect hyponatremia, hypokalemia, hypochloremia, and metabolic alkalosis 1
The American College of Cardiology suggests obtaining a complete blood count to assess for anemia and other hematologic abnormalities common in malnutrition 1
The American College of Cardiology advises performing an electrocardiogram to evaluate for QTc prolongation, which is common in both eating disorders and POTS 1
Assessing orthostatic vital signs, including heart rate and blood pressure changes from lying to standing, is recommended 1

The American College of Cardiology recommends implementing carefully controlled re-feeding to reduce the risk of ventricular arrhythmias and sudden cardiac death 2, 3
The American College of Cardiology advises avoiding prolonged, unbalanced, very low-calorie diets as they may provoke life-threatening ventricular arrhythmias 2, 3
Monitoring for "re-feeding syndrome" during the first week of re-feeding, especially in severely malnourished patients (less than 70% ideal body weight), is crucial 2, 4
Paying particular attention to phosphate levels, as hypophosphatemia during re-feeding can trigger cardiac complications, is recommended 4

The American College of Cardiology notes that cardiac complications of re-feeding syndrome typically occur within the first week and are associated with severe malnutrition 4
The American College of Cardiology recognizes that most cardiac manifestations of anorexia nervosa, including QTc prolongation, are reversible with appropriate re-feeding 4

Evaluate for comorbid conditions including anxiety, depression, and panic disorder, which are common in both POTS and eating disorders 5
Encourage increased salt and fluid intake to expand plasma volume and improve orthostatic tolerance 6

For hyperadrenergic POTS: Beta-blockers may be considered for ongoing management in patients with symptomatic inappropriate sinus tachycardia 7
Ivabradine is reasonable for ongoing management in patients with symptomatic inappropriate sinus tachycardia 7
The combination of beta-blockers and ivabradine may be considered for ongoing management in patients with inappropriate sinus tachycardia 7