Cardiac responses to exercise distinguish postural orthostatic tachycardia syndrome variants

We previously showed that one‐third of adolescents with postural orthostatic tachycardia syndrome (POTS) have hyperkinetic circulation. In a subsequent cohort, we compare participants with POTS grouped according to cardiac output ([Formula: see text]) versus oxygen uptake ([Formula: see text]) function, whose circulatory response to exercise lay at the lower end of this distribution. We hypothesized that such grouping determines the circulatory response to incremental‐protocol, upright, cycle ergometry by whatever blend of flow and resistance adjustments best maintains normal blood pressure. We reviewed data on 209 POTS participants aged 10–19 years (73% female) grouped as follows: [Formula: see text] < 3.20 L·min(−1) per L·min(−1) were designated low [Formula: see text] or hypokinetic variant (N = 31); normal‐ [Formula: see text] had slopes between 3.21 and 7.97; hyperkinetic participants had [Formula: see text] slope >8 L·min(−1) per L·min(−1) (N = 32). Heart rate response to exercise was virtually identical in each group. Mean stroke volume (SV) rose normally in the hyperkinetic group (51 ± 38%); less in the normal [Formula: see text] group (22 ± 27%); but was flat in the low [Formula: see text] group (−7 ± 16%). Mean arterial pressure was similar at rest while systemic vascular conductance was flat from rest to exercise in the hypokinetic group, and by comparison rose more steeply in the normal [Formula: see text] (P < 0.001) and in the hyperkinetic (P = 0.02) groups. In conclusion, we identified a variant of POTS with a hypokinetic circulation maintained by a vasoconstricted state. We speculate that they cannot muster preload to augment exercise SV due to profound thoracic hypovolemia, and must resort to vasoconstriction in order to maintain perfusion pressure within working muscle.