<span class="center-menu">← <small>PREVIOUS: [[3.2. Viral Infections and Autoimmune mechanisms]]</small> | <small>NEXT: [[3.4. Comorbidities and associated conditions]]</small> →</span> -------- ##### Summary >[!Summary] >- 41% report that symptoms started within 3 months of a specific event: infection (41%), surgery (12%), pregnancy (9%), vaccination (6%), accident (6%), puberty (5%), concussion (4%) or emotional stress or trauma (3%)[[#^3]] >- POTS has also been shown in patients with a remote history of traumatic head injury[[#^5]] >- may be also precipitated by vaccination or period of intensive psychosocial stress [[#^6]] >- associations between the development of POTS and recent receipt of the human papillomavirus vaccine[[#^7]] > >**Precipitants exacerbating symptoms** >- physical exertion[[#^2]] >- heat exposure[[#^2]] (53.3%[[#^1]]) >- postprandial state 23.7%[[#^1]] >- heavy meals[[#^2]] >- prolonged recumbency[[#^2]][[#^8]] >- menses[[#^2]] >- drugs (such as diuretics and vasodilators)[[#^2]] >- standing still[[#^4]] >- alcohol ingestion[[#^4]] -------- >*“Several precipitants caused a worsening of symptoms: exercise or heat exacerbated symptoms in 53.3% of patients each. A less common precipitant of symptoms was the postprandial state (23.7% of patients).” *<small>([[Thieben-2007]], [p. 3](zotero://open-pdf/library/items/5WXWEQWX?page=3&annotation=Q32KWPRF))</small>^1 >_“As in all types of orthostatic intolerance, typical exacerbating factors include heat exposure, physical exertion, heavy meals, prolonged recumbency, menses, and drugs such as diuretics and vasodilators.”_ <small>([[Benarroch-2012]], [p. 2](zotero://open-pdf/library/items/WEZLT9QC?page=2&annotation=G9PPF7YS))</small>^2 >*“There were 1933 (41%) participants who reported that their symptoms started within 3 months of a specific event. Of these, the most common triggers were an infection (n = 788; 41%), surgery (n = 237; 12%) or pregnancy (n = 163; 9%). Others included a vaccination (n = 119; 6%), an accident (n = 105; 6%), puberty (n = 86; 5%), a concussion (n = 82; 4%), or emotional stress or trauma (n = 49; 3%).” *<small>([[Shaw-2019]], [p. 3](zotero://open-pdf/library/items/48AJ3KVL?page=3&annotation=3LKLQRJP))</small>^3 >*“Symptom triggers—Patients frequently report symptom onset following acute stressors (e.g., pregnancy, a traumatic event, surgery, or a viral illness) [2;26]. Symptoms can be exacerbated by simple activities of daily life like standing still, exercise, food or alcohol ingestion, or heat exposure [26].” *<small>([[Garland-2015]], [p. 4](zotero://open-pdf/library/items/CAWTWYLR?page=4&annotation=97PVDRQI))</small>^4 >_“POTS has also been shown in patients with a remote history of traumatic head injury”_ <small>([[Benarroch-2012]], [p. 4](zotero://open-pdf/library/items/WEZLT9QC?page=4&annotation=JHGSSFQU))</small>^5 >*“The onset of POTS may be precipitated by typical immunological stressors such as viral infection, frequently of the upper respiratory or gastrointestinal tract, vaccination, trauma, pregnancy, surgery or even a period of intensive psychosocial stress [17, 21, 23–29]. The antecedent history of suspected viral infection is reported by between 20% and 50% of all patients [23, 26]. However, a substantial number of POTS patients do not report any triggering event and experience rather slowly progressing or even stationary symptoms over a long period of time [21].” *<small>([[Fedorowski-2019]], [p. 3](zotero://open-pdf/library/items/BZ35QDLR?page=3&annotation=VM36S36S))</small>^6 >*“associations between the development of POTS and recent receipt of the human papillomavirus vaccine have started to appear in the literature.”* <small>([[Wells-2017]], [p. 3](zotero://open-pdf/library/items/HLELIN7I?page=3&annotation=YG7NUQXD))</small>^7 >_“These findings indicate the presence of physical deconditioning, which may be an important factor in the development of orthostatic symptoms, regardless of the underlying pathophysiology. Bed rest or deconditioning also decreases the gain of the vasoconstrictor baroreceptor reflex and the vestibulosympathetic reflex, which could also predispose patients to orthostatic intolerance.” <small>([p. 4](zotero://open-pdf/library/items/WEZLT9QC?page=4&annotation=T8FFXDHV))</small> However, there is evidence that bed rest or deconditioning does not primarily affect the reflex control of muscle sympathetic nerve activity.”_ <small>([[Benarroch-2012]], [p. 4](zotero://open-pdf/library/items/WEZLT9QC?page=4&annotation=AV5NICCL))</small>^8