Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia, a disorder of the autonomic nervous system. It primarily affects heart rate and blood circulation when moving from lying down to standing. People with POTS experience a rapid increase in heart rate (tachycardia) upon standing, often accompanied by dizziness, palpitations, fatigue, brain fog, and in some cases fainting.
POTS is more common in young women between the ages of 15 and 50, but it can affect men and people of any age. The exact cause is not fully understood, though it is often associated with viral illnesses, autoimmune conditions, connective tissue disorders, or after major surgery or trauma.
Although POTS can be life-altering and significantly impact quality of life, it is not typically life-threatening. With proper diagnosis, management, and lifestyle adaptations, many people experience significant improvement in their symptoms.
POTS presents differently from person to person, but the hallmark feature is a sustained increase in heart rate of at least 30 beats per minute (bpm) within 10 minutes of standing (or 40 bpm in adolescents), without a significant drop in blood pressure.
Rapid heartbeat (palpitations) upon standing
Chest discomfort or tightness
Lightheadedness or near fainting
Fainting (syncope) in severe cases
Dizziness and unsteadiness
“Brain fog” (difficulty concentrating, poor memory, slowed thinking)
Headaches and migraines
Visual disturbances (blurred or tunnel vision)
Severe tiredness not relieved by rest
Difficulty with physical activity
Post-exertional malaise (worsening of symptoms after activity)
Frequent dizziness, palpitations, or fainting spells upon standing
Persistent fatigue interfering with daily life
Chest pain or shortness of breath with exertion
Sudden worsening of symptoms after a viral infection, surgery, or pregnancy
Symptoms suggestive of an underlying condition (e.g., autoimmune disease, thyroid disorder, Ehlers-Danlos syndrome)
Chest pain with exertion (rule out coronary artery disease)
Severe fainting with injury
Sudden neurological symptoms (slurred speech, weakness, loss of vision – rule out stroke)
Diagnosing POTS can be challenging as symptoms often mimic other conditions. A detailed history, physical examination, and autonomic function tests are crucial.
Sustained increase in heart rate ≥30 bpm (≥40 bpm in teenagers) within 10 minutes of standing or head-up tilt,
No significant fall in blood pressure (distinguishing from orthostatic hypotension),
Symptoms present for at least 6 months,
Exclusion of other causes such as dehydration, anaemia, thyroid disease, or heart rhythm disorders.
Tilt Table Test
Gold standard for diagnosis.
Patient is strapped to a table tilted from lying to upright position while heart rate and blood pressure are monitored.
Active Stand Test
Simpler bedside test, measuring HR and BP lying down and at intervals after standing.
Blood and urine tests
To rule out thyroid disease, diabetes, anaemia, adrenal disorders.
Electrocardiogram (ECG)
Excludes arrhythmias and structural heart disease.
Echocardiogram
Evaluates heart structure and function.
Autonomic nervous system testing
Sweat tests, deep breathing tests, Valsalva manoeuvre.
Increased fluid intake: At least 2–3 litres per day.
High salt diet (unless contraindicated): 8–10 g of salt daily to increase blood volume.
Compression stockings or abdominal binders: Prevent blood pooling in legs.
Slow postural changes: Move gradually from lying to standing.
Exercise program: Focus on recumbent cycling, rowing, swimming before upright exercise.
Sleep with head of bed elevated: Improves blood pressure regulation.
Avoid triggers: Heat, dehydration, alcohol, prolonged standing.
Beta-blockers (propranolol, bisoprolol): Reduce heart rate and palpitations.
Ivabradine: Slows heart rate without lowering blood pressure.
Fludrocortisone: Expands blood volume.
Midodrine: Constricts blood vessels to improve circulation.
Pyridostigmine: Improves autonomic function in some cases.
SSRIs or SNRIs: May help with autonomic balance and anxiety symptoms.
Cardiologist (especially electrophysiologist) for heart rhythm and circulation control.
Neurologist for autonomic dysfunction.
Physiotherapist for exercise rehabilitation.
Psychological support for coping with chronic illness.
Living with POTS requires daily adaptations:
Structured daily routine to minimise symptom flare-ups.
Regular small meals (large meals can worsen symptoms).
Carry water and salty snacks when outside.
Cooling measures in hot weather (fans, cooling vests).
Workplace/school accommodations (flexible scheduling, ability to sit/lie down).
Support networks: POTS UK, Dysautonomia International, standing for POTS.
Emotional wellbeing is crucial. Many patients face delayed diagnosis and disbelief. Psychological support and connecting with others facing POTS can greatly improve resilience.
POTS is chronic but variable. Some people experience spontaneous improvement over time, especially adolescents and young adults.
Around 25–50% significantly improve within 5 years, especially with proper management.
Some individuals continue to have persistent symptoms into adulthood.
Prognosis is best when secondary causes (autoimmune, post-viral) are identified and treated.
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