Skip to main content


Log in

Low iron storage and mild anemia in postural tachycardia syndrome in adolescents

  • Research Article
  • Published:
Clinical Autonomic Research Aims and scope Submit manuscript



We reported low iron storage in neurally mediated syncope (NMS). While reduced red cell mass indicative of anemia has been reported in POTS, iron indices and hemoglobin (Hb) data were not reported. We investigated whether POTS, like NMS, is associated with low iron storage and anemia.


Thirty two children evaluated in 2007 and 2008 for probable POTS by a standing or tilt test or both at Texas Children’s Hospital were included in a retrospective study. We measured serum ferritin (SF) and Hb values. We defined iron deficiency as SF < 12 μg/L, low iron storage as SF ≤ 25 μg/L, anemia as low Hb values for age and sex, and POTS as ≥2 symptoms of orthostatic intolerance >3 months and increased HR of >30 BPM or HR of >120 BPM within 10 min of standing or 70° tilt.


Twenty four children had POTS, ages 12–18 years, 17 (71 %) were females. Value range (median) of SF 2–289 μg/L (25), Hb 11.5–14.6 (12.5) in females and 12–15.9 g/L (13.6) in males. Patients with POTS, when compared with normal US pediatric population had higher prevalence of low iron storage (50 vs. 14 %), iron deficiency (25 % of teenage girls vs. 9 %, and 16 % of teenage boys vs. 1 %), and anemia (18 % of teenage girls vs. 1.5 %, and 43 % of teenage boys vs. 0.1 %).


Low iron storage and mild anemia are associated with POTS suggesting that low iron storage is a potentially pathophysiologic factor in both POTS and NMS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others



Serum ferritin






Postural tachycardia syndrome


Orthostatic hypotension




  1. Jarjour IT, Jarjour LK (2008) Low iron storage in children and adolescents with neurally mediated syncope. J Pediatr 153:40–44

    Article  PubMed  CAS  Google Scholar 

  2. Schondorf R, Low PA (1993) Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysautonomia? Neurology 43:132–137

    Article  PubMed  CAS  Google Scholar 

  3. Streeten DHP, Thomas D, Bell DS (2000) The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome. Am J Med Sci 320:1–8

    Article  PubMed  CAS  Google Scholar 

  4. Biaggioni I, Robertson D, Krantz S, Jones M (1994) The anemia of primary autonomic failure and its reversal with recombinant erythropoietin. Ann Intern Med 121:181–186

    Article  PubMed  CAS  Google Scholar 

  5. Hoeldtke RD, Streeten DH (1993) Treatment of orthostatic hypotension with erythropoietin. N Eng J Med 329:611–615

    Article  CAS  Google Scholar 

  6. Hoeldtke RD, Horvath GG, Bryner KD (1995) Treatment of orthostatic tachycardia with erythropoietin. Am J Med 99:525–529

    Article  PubMed  CAS  Google Scholar 

  7. Perera R, Isola L, Kaufmann H (1995) Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure. Clin Auton Res 5:211–213

    Article  PubMed  CAS  Google Scholar 

  8. Beutler E, Larsh SE, Gurney CW (1960) Iron therapy in chronically fatigued, non-anemic women: a double-blind study. Ann Intern Med 52:378–394

    Article  PubMed  CAS  Google Scholar 

  9. Vaucher P, Druais PL, Waldvogel S, Favrat B (2012) Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ 184:1247–1254

    PubMed  Google Scholar 

  10. Looker AC, Dallman PR, Carroll MD, Bunter EW, Johnson CL (1997) Prevalence of iron deficiency in the United States. JAMA 277:973–976

    Article  PubMed  CAS  Google Scholar 

  11. Halterman JS, Kaczorowski JM, Aligne CA, Auinger P, Szilagyi PG (2001) Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics 107:1381–1386

    Article  PubMed  CAS  Google Scholar 

  12. Jarjour IT, Jarjour LK (2009) Low iron stores in postural tachycardia syndrome in adolescents. Clin Auton Res 19:277

    Google Scholar 

  13. Vernino S, Low PA, Fealey RD, Stewart JD, Farrugia G, Lennon VA (2000) Autoantibodies to ganglionic acetylcholine receptors in autoimmune autonomic neuropathies. N Engl J Med 343:847–855

    Article  PubMed  CAS  Google Scholar 

  14. Low PA, Denq JC, Opfer-Gehrking TL, Dyck PJ, O’Brien PC, Selzak JM (1997) Effect of age and gender on sudomotor and cardiovagal function and blood pressure response to tilt in normal subjects. Muscle Nerve 20:1561–1568

    Article  PubMed  CAS  Google Scholar 

  15. Freeman R (2008) Current pharmacologic treatment for orthostatic hypotension. Clin Auton Res 18(Suppl 1):14–18

    Article  PubMed  Google Scholar 

  16. Low PA, Sandroni P, Joyner M, Shen WK (2009) Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol 20:352–358

    Article  PubMed  Google Scholar 

  17. Peltier AC, Garland E, Raj SR, Sato K, Black B, Song Y, Biaggioni I, Diedrich A, Robertson D (2010) Distal sudomotor findings in postural tachycardia syndrome. Clin Auton Res 20:93–99

    Article  PubMed  Google Scholar 

  18. Ekblom B (1996) Iron deficiency anemia and physical performance. In: Hallberg L, Asp NG (eds) Iron Nutrition in Health and Disease. The Swedish Nutrition Foundation 20th International Symposium. John Libbey and Company, London, pp 195–203

  19. Brownlie T, Utermohlen V, Hinton PS, Giordano C, Haas JD (2002) Marginal iron deficiency without anemia impairs aerobic adaptation among previously untrained women. Am J Clin Nutr 75:734–742

    PubMed  CAS  Google Scholar 

  20. Holloszy J (1975) Adaptation of skeletal muscle to endurance exercise. Med Sci Sports Exerc 7:155–164

    Article  CAS  Google Scholar 

  21. Liao Y, Chen S, Liu X, Zhang Q, Ai Y, Wang Y, Jin H, Tang C, Du J (2010) Flow-mediated vasodilation and endothelium function in children with postural orthostatic tachycardia syndrome. Am J Cardiol 106:378–382

    Article  PubMed  Google Scholar 

  22. Choi JW, Pai SH, Kim SK, Ito M, Park CS, Cha YN (2002) Iron deficiency anemia increases nitric oxide production in healthy adolescents. Ann Hematol 81:1–6

    Article  PubMed  CAS  Google Scholar 

  23. Stewart JM (2008) Reduced iron stores and its effects on vasovagal syncope (simple faint). J Pediatr 153:9–11

    Article  PubMed  Google Scholar 

  24. Rao SV, Stamler JS (2002) Erythropoietin, anemia, and orthostatic hypotension. The evidence mounts. Clin Auton Res 12:141–143

    Article  PubMed  Google Scholar 

  25. Li J, White J, Guo L, Zhao X, Wang J, Smart EJ, Li XA (2009) Salt inactivates endothelial nitric oxide synthase in endothelial cells. J Nutr 139:447–451

    Article  PubMed  CAS  Google Scholar 

  26. Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, Lennon VA, Shen WK, Low PA (2007) Postural orthostatic tachycardia syndrome: the Mayo Clinic experience. Mayo Clin Proc 82:308–313

    PubMed  CAS  Google Scholar 

  27. Garland EM, Winker R, Williams SM, Jiang L, Stanton K, Byrne DW, Biaggioni I, Cascorbi I, Phillips JA 3rd, Harris PA, Rüdiger H, Robertson D (2005) Endothelial NO synthase polymorphisms and postural tachycardia syndrome. Hypertension 46:1103–1110

    Article  PubMed  CAS  Google Scholar 

  28. Koma LM, Kirberger RM, Scholtz L, Bland-van den Berg P (2005) Influence of normovolemic anemia on Doppler-derived blood velocity ratios of abdominal splanchnic vessels in clinically normal dogs. Vet Radiol Ultrasound 46:427–433

    Article  PubMed  Google Scholar 

  29. Gamboa A, Okamoto LE, Raj SR, Diedrich A, Shibao CA, Robertson D, Biaggioni I (2013) Nitric oxide and regulation of heart rate in patients with postural tachycardia syndrome and healthy subjects. Hypertension 61:376–381

    Article  PubMed  CAS  Google Scholar 

  30. Singer W, Sletten DM, Opfer-Gehrking TL, Brands CK, Fischer PR, Low PA (2012) Postural tachycardia in children and adolescents: what is abnormal? J Pediatr 160:222–226

    Article  PubMed  Google Scholar 

  31. Jarjour IT, Hernandez AM, Jarjour LK (2012) How important is the T in POTs using pediatric versus adult diagnostic criteria for postural tachycardia? Clin Auton Res 22:251

    Google Scholar 

  32. Jacob G, Raj SR, Ketch T, Pavlin B, Biaggioni I, Ertl AC, Robertson D (2005) Postural pseudoanemia: posture-dependent change in hematocrit. Mayo Clin Proc 80:611–614

    Article  PubMed  Google Scholar 

Download references


Baylor College of Medicine.

Conflict of interest

There is none to disclose.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Imad T. Jarjour.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jarjour, I.T., Jarjour, L.K. Low iron storage and mild anemia in postural tachycardia syndrome in adolescents. Clin Auton Res 23, 175–179 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: