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Part TWO: Postural Orthostatic Tachycardia Syndrome (POTS) with Dr Mark Donohoe

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Part TWO: Postural Orthostatic Tachycardia Syndrome (POTS) with Dr Mark Donohoe

What nutrients or herbs would you use to treat a POTS patient with an “impending sense of doom?’

In the second episode of this two part series, Dr Mark Donohoe returns to discuss the treatment considerations for Postural Orthostatic Tachycardia Syndrome, or POTS. He helps us differentiate between the various subcategories of how the condition presents, and what treatments to consider, including nutrients, herbs and lifestyle suggestions. 

Covered in this episode

[00:47] Welcoming back Dr Mark Donohoe
[01:38] Review: What is POTS?
[03:05] Subcategories of POTS
[05:08] Low blood pressure and the sense of impending doom
[06:29] Monitoring blood pressure
[09:27] Differences between atrial fibrillation and POTS
[14:55] The role of magnesium and B12
[19:39] Excess water and electrolyte imbalances 
[26:42] Ehlers-Danlos Syndrome and POTS
[32:06] Yoga and POTS
[34:17] Herbal therapeutics
[39:11] Closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us again in the studio today is Dr Mark Donohoe who earned his medical degree from Sydney Uni in 1980. And he worked around the central coast of New South Wales honing his medical skills, where his interest in integrative medicine sparked because patients just weren't fitting into the black boxes of diagnosis and treatment which were drummed into him in medical school. Mark is highly revered as one of the fathers of integrative medicine in Australia, and he is always the vanguard for his patients' health. Welcome back to FX Medicine, Mark. How are you?

Mark: I'm well, but feeling older every time I hear the introduction. Clearly it's time that we change this around a little bit.

Andrew: We need to modernise you, Mark.

Mark: We do.

Andrew: Part [your hair] on the different side.

Mark: Come into the 21st century.

Andrew: That central part just doesn't work for you. 

Mark, today we're carrying on from our last podcast on POTS. So let's go through just a brief review. What's POTS?

Mark: The briefest review is, POTS is a tachycardia syndrome. It's people who, you know, I see with fatigue, weakness, and a distressing autonomic alteration. Which is their heart going into a kind of very rapid heart rate. They pick it up as palpitations, they talk about it. Often it goes along with things like sweating, poor quality of sleep. There's a whole array of things that go with this. And POTS has become a super popular acronym for, what it means is “Postural Orthostatic Tachycardia Syndrome.”

However, it's become a catch-all phrase for a lot of different conditions that I'd love to just break open a little bit today. At its purest, POTS is just a fast heart rate… Say, at rest, sitting or lying, you've got a heart rate, say, of 70, 80, or 90. You stand up, and if in that first 10 minutes of standing up, the heart rate without any activity, goes up by 30 beats a minute, in an adult, or 40 beats a minute if you're a teenager, then that is purely the definition of POTS. You don't have to do anything more, it's a test that can be done in the home. You can get people to do this and just take the pulse rate every minute for that 10 minutes and get a very, very clear separation of POTS. That is the kind of headline of it. 

The breaking it down into subcategories, where some of those people keep their blood pressure normal. The majority of people with chronic illness also drop their blood pressure at the same time that the pulse rate is up. And you'll often see a blood pressure go from, say, the lowest end of 110 on 60 or 70. They stand up and it drops to 80 on 50, and they're feeling dizzy and unwell. And then they're sweating, and then they just have to sit down. 

There are also tachycardia people whose blood pressure is normal or high, doesn't vary one iota, and that also is true POTS, that is pure tachycardia arrhythmia. And you still have the same diagnosis, but there are many different treatments compared to those that drop their blood pressure.

And there are even hypotensive people, which we probably all know, the people whose heart rate never seems to drop, goes up with the slightest stress or slightest push, slightest irritation. And it goes up rapidly, as does the blood pressure. And these are the kind of type A of always the pulse is high, the heart is over-beating, it's too strong a response to a kind of catecholamine. So it covers a range of things. We're going to limit it to abnormalities of the vascular system with a fast heart rate. And then we can break that down a little bit as to, what if your blood pressure is dropping? What if your blood pressure is stable? How do we slow down a heart to make it run more efficiently?

So today, we're going to break that down into what's the different types of "POTS"? What do we do as practitioners about each of those different types? What are the treatment options, and what's effective and ineffective? And so we're in an area, cardiologists hate it. Cardiologists always think, "I'm going to come to a conclusion about this, I know what this is going to be," and routinely, they'll say, "There is no cardiovascular disease. There is no damage here. You don't have heart disease. Go home and rest." And usually what they'll say is, "Don't stress yourself," which is, of course, a stressful thing when a person has got heart symptoms.

Andrew: Don't stress yourself, forever.

Mark: Yeah, you have got heart symptoms, you think you might be dying. And that's one really important thing. A lot of the patients, when they drop their blood pressure, have this sense, what we love to call in medicine, “a sense of impending doom,” you know. Like every time I come to do a podcast here, there's a sense of impending doom. And they say, "I feel like I'm going to die." Now, they're not going to die. You know, this is a fast heart rate, it's 120, 130 beats...

Andrew: You don't know that when...

Mark: That’s right. But that does give a little bit of a clue, because when blood pressure drops, the body's response is, "Hell, I've lost blood somewhere," and that's usually very bad news in evolutionary terms. So that sense of impending doom is, in fact, a very reasonable response of the body to say, "Where's my blood pressure? Where's my fuel supply? What's happened?" And so that's where many people literally fall to the ground.

Lots of people with the hypotensive POTS keep on collapsing, keep on having these syncopal attacks. And weirdly, they go to hospital, the hospital says, "Nothing wrong with you, we'll just stick a saline drip in." Two litres of saline and these people are bounding out, saying, "Well, that's curative." The doctors in the hospital interpret that as, "Well, that's a placebo effect so it just proves that these people are crazy." It doesn't prove that at all. You know, two litres of saline...

Andrew: Transient doesn't mean placebo.

Mark: Yeah, that's right.

Andrew: Mind you, if it's repeated… I guess, the whole thing is that you need to prove to somebody that… A doctor can only see what a doctor can see. 

Mark: Yes.

Andrew: And if they can't see it, how do you know it's happened? So, monitoring, you know, Holter monitors, things like that.

Mark: There are these new blood pressure monitors...

Andrew: That the home...

Mark: The home blood pressure monitoring.

Andrew: Hell, you’ve got a watch these days.

Mark: Well, you have got that. But when you're monitoring blood pressure, you can't get away from the fact that the sphyg[momanometer] has to expand and it hurts, and you know when you're being monitored. So it never got over the white coat hypertension as much as we wanted. This is white coat hypotension. But if it keeps on inflating every hour at night, it also disturbs sleep for that night. And so we have the complexity of “how do you ever find out what the blood pressure is really doing without your measurement interfering with the very process?”

We can get the watches and things following the heart rate and making sure there's dipping of the heart rate, making sure that the interbeat variability, which is the heart rate variability, is expanded at night. So there are indirect measures we can get. But the best and simplest thing, as you said, is a Holter monitor. Put something on that just watches the pulse rate all the way through the day. 

I've got to say that when the Holter monitors are done, they report saying, "There's no cardiovascular disease," but, you know, there are no ventricular ectopics. There are none of those, which we don't think there are. But it is interesting to see that kind of heart rate variability. But now you can do more on a watch. You know, a good sports watch will do that measurement better than the others because we've got to wear chest monitors and it varies your day around. 

But I would say, nearly everybody who's got what seems to be POTS, that rapid heart rate rise, would always have blood pressure variation, deserves to see a cardiologist. Why? Because there are serious conditions, adrenal conditions and vascular conditions that can be confused with this.

And the best thing that, I think, happens is the good cardiologist say, "No, this is POTS, and it's not part of my area of expertise. Go back and try the following XXX," which we'll talk about today. The worst cardiologists, in my opinion, are ones that want to go hammer and tongs until they prove every last detail of what's going on with this person. And $25,000 later, and a lot of interventions like tilt-table testing and other testing that leaves people sick for days or weeks afterwards, they will pursue it till the bitter end.

And so, one of the jobs, I think, of us as integrative doctors and of non-medical practitioners is to be aware that the 90% likelihood is that this is a benign condition that we can go and help the person look after. But we've got to take the curse off it by having a cardiologist say, "Yep, this is nothing serious," but stop them from going down that road of, you know, interminable investigations that lead nowhere.

Andrew: But importantly you've got, you know, what, 3% to 5% of the Australian population with atrial fib. Which requires treatment, or you're at risk of stroke. 

Mark: Yeah.

Andrew: You know, there are certain conditions that we've got to be aware of to differentially diagnose from. So is the hallmark that it's a normal sinus rhythm with no decompensation, a normal ST segment, a normal QRS complex...

Mark: Standard cardiograph for a 24-hour monitor gives you a little bit of a hint in those areas. So the answer is yes, if there are abnormalities on the electrocardiogram, if there are conduction defects along the way, then those are things we pay attention to. A lot of the medications used by doctors interfere with that conduction and they slow the heart by particular tricks, but that's the reason for the cardiologist. I think the world of AFib is changing rapidly as we get more and more of the monitors on wrists that are really capable of picking up periods of atrial fibrillation. We're seeing way more people.

Now, the problem with that is we're seeing so many more people with it that we never knew had atrial fibrillation, that it may be a little bit like screening for breast cancer or many things. When you screen, you see, "Oh, wow, there's five times as many as we ever thought." It may be relatively normal for people under stress, under certain nutritional conditions to flip into AFib and then flip out of it.

Andrew: Paroxysmal.

Mark: Yeah, and we don't know those people, and we don't know if our treatment helps. We do know our treatment helps when a person is in persistent atrial fibrillation, and the risk of the clotting, as you said, the risk of embolism up to the brain. We know very well that the anti-clotting and the anticoagulation factors do a good job in that area of preventing the stroke and the negative outcome. We're much less good at getting the rhythm back in. And, you know, we go brutally from cardioversion, you know, electrical stimulation of the heart, there's lots and lots of drugs around, a lot of them have a lot of negative side effects. And so you've got to be careful that you're treating the right person.

I have dozens of my patients with intermittent atrial fibrillation who, if they keep their magnesium up, maintain sinus rhythm for long, long periods of time. Often months. They get themselves under stress, they stop taking their magnesium, their diet falls away, and suddenly they're flipping right back into AFib. What happens? They go and see their doctor then, who thinks that they've been in atrial fibrillation the whole time. 

So I do think that there are ways of saying to a person, "Before we get on to long term treatment of atrial fibrillation, let's just make sure that it is a problem and you can't fix it very, very simply."

And that use of the magnesium, you know, that 300 milligrams or so a day, people who are inclined to take it can remain in sinus rhythm if they don't have a cardiac defect in the first place. 

So slowing the heart and getting it to fall back into rhythm is often a matter of stress management, yoga, you know, meditation. People having the tools to be able to reduce the catecholamine, a tendency to push the pulse up. Not getting them to the point where they flip into atrial fibrillation all the time.

But you need a cardiologist to say, "This is, or is not, a problem." And I think that that's the point that when you see a person who's saying, "Look, my heart is going off," you want to have that authoritative position to say, "This is not a serious condition, it's not atrial fibrillation, it needs to be managed." But now you go down into the belly of the beast and you figure out, what type of POTS is this? Is this a vascular response? Is it hypotensive? What do we do about it?

I think that's what we should do today is say, once the cardiologist has said, "I'm not sure that I can help. Why don't you try fludrocortisone, or why don't you try ivabradine, why don't you try..." They have their favourite drugs. Once they've said that, could we as practitioners say, "Okay, thank you. Let's start a little bit lower level. Let's get stress management, let's get diet, let's get magnesium. Let's do simple things first and find out what we've accomplished there"? If it's not a serious disease, POTS is entirely a matter of recovering from the symptoms. If you are not getting the tachycardia, if you're not dropping your blood pressure, then that's not playing a part in your health.

So we can, as practitioners, do very simple things to bring the heart rate down, to bring the blood pressure up, and we should learn those to be able to say to a person, "Here's how you fix it." Now, the disclaimer here is one thing. There are patients that I see. I see a lot of chronic fatigue syndrome patients. They look to be pure POTS, they stand up and their pulse rate goes high and the blood pressure drops low and you think, "This is easy. I'm going to fix this person and they're going to be well." There are dozens of my patients now who I've fixed with the POTS. The heart rate is stable, the blood pressure is stable, and they are no better than they were before.

So I don't want to get into this thing of “it's all POTS.” POTS becomes just a throwaway term that we say, "You've got POTS," as if what can we do about it? 

What we do know is that half of all POTS patients are triggered by a viral infection. Lots of chronic fatigue syndrome patients are triggered by a viral infection. There are two different things going on here. One of them can be neurological autonomic. But fixing that peripheral thing doesn't always fix the underlying condition. So you need that disclaimer to say, even when you get POTS right, plenty of patients may still be unwell for a post-viral reason that has nothing to do with the vascular system.

Andrew: When you've got a normal sinus rhythm and the cardiologist has given the all-clear that there's nothing heart related driving this condition...

Mark: No pathology of the heart.

Andrew: No pathology of the heart or associated vessels. What about things like baroreceptor, do I say, pathology? Dysfunction? 

Mark: Yeah.

Andrew: Issues with, you know, renal reabsorption, natriuretic hormone. So, how far does one investigate before saying “It's okay?” You know, for instance, I'm really interested in the link between POTS and IBS. So there you're talking about the...

Mark: Very high...

Andrew: ...gut, brain, heart, vagal nerve link.

Mark: Very high. Look, I think that you've hit right on the issue that once you know it's not the heart, it's the control system of the heart. It's the way the body interprets a stress response and the old, you know, Hans Selye type stress response of, it could be physiological, viral. It could be emotional. It could be just about anything. 

But the way the bodies respond in a stress response has high variability in the community. And a lot of the time, what we're trying to pick is, what's the stimulus that tells the body to go into this state? Can we undo that stimulus? Now, sometimes it's really straightforward. You do...you know, you assess them nutritionally, they've got really low magnesium levels, a surprising number of people have…

Andrew: Serum?

Mark: No, serum… I do the red cell magnesium still.

Andrew: Red cell, yeah.

Mark: I know that the serum and those correlate, but the red cell is, I think, better. But low red cell magnesium can be a bugger of a thing to pick up. We do think that in chronic fatigue syndrome there are these things called “magnesium-calcium channelopathies” and “sodium-potassium channelopathies,” where the body just struggles to keep the intracellular magnesium at a sufficiently high level. But you can use the mass effect, you can just say, "Here's an extra 300 or 400 milligrams of magnesium," and you can force feed the body a bit of magnesium so that it is there to balance the calcium channel.

And a lot of the work is being done now to say that magnesium threonate may be better in doing that job than magnesium glycinate. Partly neuromuscular, partly autonomic. And the threonate, at the moment, is just way more expensive. So we tend to use, you know, the cheapest and easiest available.

Andrew: I mean, we saw that with lipoic acid. 

Mark: Yeah.

Andrew: I remember the day when it was just exorbitant. It was worse or better than gold. And then...

Mark: And they come under control eventually.

Andrew: And then, bang, almost overnight it quartered in price. Kind of like Viagra.

Mark: If there is sufficient... Yeah. I think that is a patent issue and I'm not sure that magnesium is still a patent going for it yet. But I do think that you've got at least simple tools like that where you can say, "If the magnesium is low, treat the low magnesium." It's still pathology. It's just not heart disease, it's autonomic. 

There are people with COMT, super sensitives. The ones that can't clear the catecholamines from their receptors, they're always a little bit tricky. They're always over-responders in a particular way to stressors. And so, a moderate to us stress, in my mind, a moderate stress of standing kicks in to suddenly push the heart rate to 140 beats a minute. And the pulse rate and the blood pressure are therefore fighting against each other to try and maintain fuel supply. So when that happens, when you can find your identifiable thing…

The other thing I would point out over and over is people who have become vegan and vegetarian, a year or two after they become vegan or vegetarian, watch out for the B12 levels that do drop away. There are a lot of methylation issues that go on in the background here. And people do head into vegan diets, feel great, and then find that they're running out of the B12. When the stores kind of run out, they start to get methylation issues going on, they get viral issues going on, they respond poorly to viral infections. And then one day you get this kind of a response.

Now, if you can get in nice and early, simply restoring B12 levels has helped a lot of patients get their rhythm back. It sounds like a dance thing, I know, but it helps them get their rhythm back. And it helps stabilise the heart. Now maybe via, you know, methylation of catecholamines, it may be for a whole lot of different reasons, but we should always focus on “There's a whole person there. This is not a heart with a high pulse rate, this is a person whose heart is responding not pathologically, but in an abnormal way to stressors.” So those are the divisions. There are some easy, simple things you get out of the way.

The other thing is, there are people out there who believe that you've got to drink five litres of water a day to, you know, wash your kidneys out. And those over-hydrators, the people who are just taking the advice of “Drink water, water, water,” wash out their sodium, they wash out their potassium. The urine can never be as dilute as the water you're drinking. And you've got to be very, very sure that you're matching it with electrolytes if you're going to go for those high amounts. 

Andrew: Right. Right.

Mark: And so the washout effect is some people just have low sodium because in the passionate belief that they're going to purge toxins from the body and make their kidneys work. They do make the kidneys work, but the kidneys are working to make the most dilute urine they possibly can, and often lose that fight.

So bringing people down on the water that they're drinking, two to three litres is fine for water. If you're going to go higher you have to have salt. You have to have the electrolytes in there to make sure that you are not just washing out all the nutrients and the electrolytes from your food.

Andrew: When you're doing your, you know, your BUN, your blood, urea, nitrogen, and your U, E's, A’s, say, urea, electrolyte, and albumin, are these typically normal? Or do you find that they are indeed low in sodium?

Mark: It's not just sodium. So there are two groups that I would separate. Lots of these patients have low urea, very low urea. So they sit there with low urea the whole time. When it comes to low blood pressure, then low sodium is typically the thing. So we have this range where we call sodium, say, 135 up. These are people who sit on 135, 136, 134, so they'll get the occasional asterisk of low sodium but they're sitting at the very bottom of the range. 

There's a whole separate group, and I have some spectacular patients in these areas, where the potassium is sitting at, say, 3.2, 3.1, a normal range of around about, say 3.5 up to a 5.5. They're sitting below that range, but you give them potassium and, say, giving the old Slow-K 600 milligrams, you give them potassium, some of these people will take up to say, 8, or 9, or 10 of the Slow-K per day, and still only get to 3.6, 3.5. A lot of them lose it straight out through the urine, and we don't understand the reasons why. A lot of them may just exist at that low level and the body keeps setting it back there. 

So the low sodium group are, by far, the most common group in this area. The low potassium group tend to have the arrhythmias that go, because the potassium is required to stabilise that. And being at 3.2 or 3.3 in a hospital setting, when they go to a hospital, they go, "It's mild hypokalemia." That's fine if it's only for an hour. It’s not fine if that's your whole life. 

A subgroup of these to pay attention to, is those with diarrhoea. Lots of people don't mention that they put up with going to the toilet with loose stools three or four or five times a day. And they just don't mention it because it's part of the background of their life. If people have chronic diarrhoea, then...

Andrew: There's a source of electrolyte loss.

Mark: The electrolyte loss is obvious, and you do something about the gut. And when the gut is settled, and the diarrhoea has stopped, they now have a bit of a chance of not losing their electrolytes out the south end. 

So, you know, those are subdivisions that we want to just keep in mind. That we focus on the heart, and the things that we're going to talk about next are what can you do for the heart, but the whole body owns that heart. And the heart often is just, you know, as we've heard in many of the BioCeuticals conferences, it's just reflecting what's going on through the rest of the body.

The vagus nerve, and the brain, and the heart, all have their inbuilt rhythms to try and keep you from doing a bad thing called dying. And often you just have to respect that this doesn't seem a sensible choice, but it may be the least worst choice that's available to the body.

Andrew: It's very similar to, you know, watching those goats that startle, you know? They just lie down. They just freeze upon the startle reflex. I'm also really interested in this low potassium.

Mark: My take on the potassium is, I think, that it's probably pathological loss of potassium. Because you do see in these people, typically, that they're peeing a lot of potassium out. Now the job of the body in a sense for sodium-potassium, is sodium stays in the vascular tissue outside the cell and potassium is shunted inside the cell. If there's a failure of that shunting, that sodium-potassium pump, then there's too much potassium in the outside, and the body keeps on excreting it, just passive excretion through the kidneys.

We haven't got a good answer to this yet. We know that the potassium goes somewhere. But why a person would be on five bananas and eight Slow-K a day to barely stretch him with the potassium that's able to keep them going, it's crazy. And when those people stop it, they become super sensitive responders to a whole lot of things. The milder stress will push them right over the edge. A food reaction will see them sick for days or weeks. So there's something about electrolyte loss, which is either a surrogate marker for something going wrong with the autonomic nervous system, or it's the cause of something going on with a hyper-responsive, a super responsiveness of the nerve endings.

Andrew: Does high catecholamines have an effect on tubular reabsorption of electrolytes, like the proximal tubule, the loop of Henle? Is there any correlation between extraordinarily high catecholamines, which is seen in some people with POTS, as you said, the COMT tissues and wasting of potassium...

Mark: And the answer to that is...

Andrew: ...instead of reabsorption.

Mark: ...I don't know. It's a good thought about what happens with potassium wasting. The catecholamines work on every single tissue in a coordinated response. They stop bowel peristalsis, they dilate pupils. There are a whole lot of effects. And one of the things that you can sacrifice at that time is your renal function for excretion. If you had the choice, you would not stop and pee while being chased by a big cat. And so there's a shutdown of functions that can be put off to a later time to focus on shunting blood to the muscles, to the central nervous system, to places where your survival may be at risk. And that's where I come back to that thing of, "I feel like I'm dying." The body will do extraordinary things to stop you feeling like you're dying, and it will sacrifice a lot of normal functions along the way.

Andrew: Okay, so we've been through a few of the nutrients.

Mark: And we've been through a few of the pathologies.

Andrew: Pathologies, and we'd mentioned...

Mark: That was just to get those out of the way and say, "If there's diarrhoea, pay attention to the diarrhoea. If there is a kidney problem, pay attention to the kidneys." If the cardiologist says, "No, this is a cardiac disorder," pay attention to that. So there are maybe 20% that will be successfully managed in a way that has nothing to do with POTS, whatsoever.

Andrew: A thing that's going around in my mind is what's happening with the actual organisation at the tissue level. So I was really interested reading that there's also a link with Ehlers-Danlos Syndrome, EDS. And that fascinates me. I know that there's a connective tissue disorder going on there. 

Mark: Yeah.

Andrew: But it's interesting...

Mark: It's not a... Hang on, be careful. Ehlers-Danlos is a variant of connective tissue, its collagen variants, which are from super flexible to very, very tight. 

Andrew: Yeah.

Mark: So it's not like a disease like you catch Ehlers-Danlos, or it's a fatal disease. It's a variant of normal super flexibility of the joints, recurrent dislocation. You run the risk of things in the extreme, like dissecting aneurysms and the like.

Andrew: Yeah, injuries.

Mark: So those kind of things, almost universally, are related to the collagen in the blood vessels, and this tendency for collagen to pull...

Andrew: It's not just in the blood vessels.

Mark: No, it's everywhere. I mean, 60% of your protein in your body is collagen. And the flexibility of the blood vessels is one of the reasons that there's a problem for people with EDS and Marfan syndrome and the related disorders. But one thought there is, when you are pushed, and you stand and you are tall, and you've got blood vessels that tend to expand, there’s pooling that goes on in the extremities. So there's a relatively easy, straightforward way of thinking about it, and that is, if you've got veins and arteries that just expand when under gravity, where does your blood go? To your legs. 

Andrew: To your feet, yeah.

Mark: And so, the Ehlers-Danlos and that group are very well managed by putting on restrictive...

Andrew: Stockings.

Mark: ...constriction of the stockings, stockings for the legs. That if you can stop the pooling in the legs by putting an artificial constriction around it, that keeps the blood vessels undilated in that area and gives you a pool of blood, which is more available to us.

Andrew: You're thinking whole hooves and horses, and I'm thinking hooves and zebras. 

Mark: Right.

Andrew: I’m wondering about, you know, visceral tissue reorganise...not reorganisation, visceral tissue organisation as well as the direct actions of the pooling of the blood.

Mark: You're not thinking of hysteria where the uterus runs around the body...

Andrew: No.

Mark: ...to lodge in certain areas and lodges in the heart.

Andrew: Not quite that flexible.

Mark: Okay, not quite flexible. Okay.

Look, an answer is, for the Ehlers-Danlos, remember to ask if they're super flexible. I make the mistake all the time of looking at the phenotype in front of me and saying, "You don't look flexible." And I say, "Were you ever very flexible?" And they go, “Ever very flexible? Look!” And they bend the thumb back and they kind of show the arms bending the other way. Just because they put on weight, it gives you the impression you're not the Marfan type person that I have always known about.

Andrew: So that's the important question to ask?

Mark: Really important because there's gastrointestinal issues. Long, curly loops of bowel. There's dysautonomias that go with that. And there is the whole issue of how do you maintain your blood pressure when the collagen that you rely on for a certain tissue integrity can be super flexible and let you down at the wrong times? Now, Ehlers-Danlos groups are coming out of the woodwork so their hallmark is the zebra, as we'd said. Why? Because they have a lot of these odd conditions that are tied together with a common collagen variant.

And so I made the mistake overall of saying, "Oh, it's a collagen disorder." It's not. It's something that in the 21st century when we're sitting up in front of computers all the time we stand up and go to the toilet, that's a difficult thing for them to manage. And they do get the postural orthostatic problems, they have more than low blood pressure. And as the blood pressure drops, the heart goes, "Hey, where's my blood?" And the brain says, "Where's my blood?" And then the pulse rate goes up to 130, 140 beats a minute to compensate for the dropping blood pressure.

And they're ones that I would separate and say, "Okay, here's our first answer, that if they've got EDS, and they look to be the classics where the blood pressure is dropping, then we could do something about the blood pressure just by putting the stockings on and see what kind of a gain is made." There is a movement in America to have these kind of special inflatable, very, very comfortable stockings and restrictions around the arms, legs precisely for this reason. So Peter Rowe has got these things together, they give a guarantee, you put them on, you try them, and you see if you restore function. And in the EDS group, they seem to be really a very good non-pharmacological method of doing it.

Others with EDS, interestingly, from my perspective anyway, do well with yoga. Now, I don't know why, I always think of inversions and things as very, very tricky things to do, but they respond well to yoga. And I don't know if that is a kind of reconditioning of the asanas being something about the reconditioning. I don't know if it's breath control, but they do seem to do well symptomatically with that. I can't tell you why, it's just an observation at the moment.

That's a full subgroup to say, if it is the blood pressure dropping - and that's driving the whole thing, whether that's low vascular volume, or whether that's for other reasons, or whether that's Ehlers-Danlos and Marfan type disorders - try the non-pharmacological, try the stockings, try the restrictive stockings, and see if there's a significant improvement. And if there is, that gets you one step towards the recovery of function there. And so when you stand up, you don't automatically go to ground.

Andrew: Speaking of yoga, is there any evidence that you've ever come across looking at convert...I don't know how you'd measure this. But conversion of angiotensin I to II with breathing rate, or depth, or rhythm?

Mark: This is something you should ask my wife who's been 30 years as a yoga teacher and is doing her studies in that area now. Yoga seems to affect almost every aspect of our physiology. And that's the thing that keeps on stunning me. A strange thing for me is...

Andrew: I'd love somebody to do this sort of stuff where you can actually show biochemical changes from an exercise, like then, right then.

Mark: It's being done, as I keep on having that pointed out by my darling wife. The stuff is done. It's done primarily by women, and women in the research community are regarded very, very lowly and the research never bubbles through to the top where the boys take all the credit.

Andrew: Don't get me started here.

Mark: Right. So having got that out of the way, there are things in yoga, and I'm convinced that breath is a part of it, and that movement is a part of it. There are signals to the body about the muscles moving in the chest, about good inspiration, about the cycle of breathing that is a coordinating factor for the cardiovascular system as well. 

So, we may not think we have direct control of the heart. We possibly do have some direct control, but via breath and via positions. I think the Ayurvedics and others would fall back on that as a primary method of treatment. I am not well enough trained in that area, you know my thing, herbs and some of the complementary therapies. I have to go back to school when I finish medicine, it's only a few years down the line, and become better at the things that I didn't know.

But that's...you know, let's just put that to one side. The yoga is worth doing. Meditation and mindfulness for people who are super responders to any stress, give them tools so that the nervous system does not fall into that rapid panic response of the heart rate going up for no particular reason and no control of it.

Andrew: So I know that you work in will with naturopaths that you trust. 

Mark: Yes.

Andrew: With regards to POTS treatments, you don't prescribe herbs, but they prescribe herbs.

Mark: They do.

Andrew: What herbs do they prescribe that you find work well in your patients, like Terminalia arjuna?

Mark: I love it when you talk dirty, Andrew. I love it when you talk dirty.

Andrew: Like, you know, good old hawthorn. 

Mark: Yeah.

Andrew: And importantly, here, in my part, I've never treated POTS, but in certain cases of heart rhythm and, you know, trophic issues, you know, the hawthorn leaves rather than the popularised berries because of their flavonoid content. I've been a fan of those, or at least mixing them. So what other things...

Mark: You do touch on my weak spot that I do have to hand that off to people who are trained in herbs.

Andrew: But surely they would have told you.

Mark: They do. They feedback, and I read what they're doing. They send the letters back to me, I send the letters to them. The one that I am interested in because it was put forward by Peter Rowe in America was the use of licorice, non-deglycerized, or whatever that term is.

Andrew: Normal licorice?

Mark: Normal licorice. What you have, as I understand it, as a problem with licorice, is it may raise blood pressure. That's the very thing that is being used and...

Andrew: It's not in everybody though, you know. You've got to use high doses and watch them.

Mark: Yeah. So my job there was, you know, with a person...

Andrew: To cause a problem, I should say.

Mark: Yeah. A person who's got low blood pressure with his POTS, how do we raise their blood pressure safely? So the standard medical advice is increase to about three litres of water per day with plenty of salt, four grams of additional salt. It's a lot of salt to put into a person. 

But the use of licorice seems to be able to do part of that job. I think it is sodium retention, and that licorice is able to maintain that. And maybe that's the way that it brings up the fluid volume, so people get out of that sense of, "I feel like I'm dying." With the liquorice and the stability of the blood pressure, they no longer feel like they're dying.

The licorice and the blood pressure don't always fix the fast heart rate. And so, the thing I'm always looking for, the classic herb that always fixes the heart rate was the poison digitalis. And so we use that on prescription as Lanoxin. And Lanoxin can be an effective way of slowing the heart, poisoning it just that little bit so it slows and beats more rhythmically, and you can get rhythm back in some of those people.

There are probably dozens of herbs that do the same kind of job of slowing the heart and allowing each heartbeat to be more effective. So I work along that line of up your fluids, up the sodium that goes in there. For the people who are low in potassium, we measure that, people low in potassium, you've always got to remember to put back the potassium. Otherwise you get more heart rhythms by that extra litre or two of water every day.

Andrew: Quick question, a dose of dig...?

Mark: Depends on the person. The people I'm talking about is 62.5 micrograms, which is...

Andrew: Micrograms, yeah.

Mark: ....Lanoxin-PG is the kind of brand name for it. But it's low dose, it's very rarely up in the very high dose area. For my patients, small amounts of almost anything. The only exception to that is magnesium. Magnesium, you can shovel the stuff in, and what you're always trying to get around is, can you deliver enough without causing diarrhoea?

Andrew: Yeah, and renal disease is the other issue. So I think it's always wise if you're going to be giving high doses of any mineral to always check their GFR and some other electrolytes.

Mark: Remember the last 40-year history of medicine is high-dose calcium, unreplaced by anything else, and now we find…

Andrew: Oops. 

Mark: …it’s a mistake. But what's happening now is they're blaming the kind of complementary doctors for doing it. It was on everyone's...

Andrew: It was standard.

Mark: ...agenda. This is the danger of supplementation. It's the danger of stupid supplementation where you give one nutrient at the exclusion of everything else. So we've got those. 

When it comes to slowing the heart rate, this is something I want to come and ask your opinion on. And the heart rate slowing for us is, you use propranolol or a beta-blocker, you stop the adrenaline effects on the body. BETALOC is a very common drug that we use. New drug is called Ivabradine, which slows the sinus rhythm without much else. But I know there's got to be other things that do it. And so that exploration of what other things...

Andrew: Yoga, vagal nerve stimulation.

Mark: Vagal nerve stimulation, you're quite right. No, I remember this...

Andrew: Magnesium.

Mark: ...from the recent conference, and did I implement it. So no, those are ways that I think…

Andrew: I really think one of the most useful, ubiquitously useful techniques for...I would just think every naturopath should learn is vagal nerve stimulation. 

We are out of time, Mark. I'd love to speak to you further about this, you and I, we'll go and have a coffee hopefully, not against the…

Mark: The trouble is that it opens up more doors every time we talk.

Andrew: I know.

Mark: We have 40 podcasts on POTS. I don't think it's going to be very popular. We've got to terminate this at some point.

Andrew: But I do always learn something from you. And at the very least, you've corrected me on the terminology that I was using, a lax terminology. And I think we really need to be very clear about our terminology. Like, if it's adrenal insufficiency, it's that. It's not adrenal fatigue. 

Mark: Yes.

Andrew: We need to leave behind these old… They might roll off the tongue but they're incorrect, and they lead us down a very dangerous path with how we're treating. We're treating the brain with chronic stress. You know, these sort of terms that we need to leave behind, I thank you very much. We, all our listeners, I think, would thank you very much for keeping us on that tight path of doing the right thing, not just incorrect vernacular, but for our patients as well. Thank you so much for taking us through the rest of POTS today.

Mark: It's been a pleasure again.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.



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