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Clinician

Blog articles for clinicians and other medical professionals.

What Clinicians Need to Know About POTS

August 20th, 2025

Overview and definition

POTS is a type of dysautonomia noted by an abnormal increase in heart rate upon standing, often accompanied by a range of debilitating symptoms. It affects the autonomic nervous system's regulation of blood flow, resulting in orthostatic intolerance.

This condition is characterized by a continued increase in heart rate of at least 30 beats per minute (bpm) within a 10-minute period of standing (or 40 bpm in individuals aged 12 to 19) without orthostatic hypotension.

POTS can affect all patient populations. It may arise after viral illness, physical trauma, pregnancy, or surgery, and is often associated with other conditions like Ehlers-Danlos syndrome, mast cell activation disorders, and chronic fatigue syndrome.

Demographics breakdown

POTS affects a wide demographic range, but it is most commonly seen in women between ages 15 and 50, with a significant peak in incidence among adolescents and young adults. Studies suggest that approximately 80% of individuals diagnosed with POTS are female.

The condition is thought to affect 1 to 3 million people in the U.S. alone, though it’s likely underdiagnosed due to overlapping symptoms with other disorders and lack of awareness among both patients and healthcare providers.

POTS may occur following viral illnesses, surgeries, traumatic injuries, or during periods of significant hormonal changes such as puberty or pregnancy. Genetic predisposition, connective tissue disorders like Ehlers-Danlos syndrome, and autoimmune conditions may also contribute to susceptibility.

Symptoms of POTS

Patients with POTS present with a diverse and often disabling symptom profile.

Common complaints include:

  • Palpitations
  • Rapid heartbeat upon standing
  • Lightheadedness
  • Dizziness
  • Fainting episodes, in some cases

Many individuals experience profound fatigue and reduced exercise tolerance, which can significantly impact daily functioning. Chest pain or discomfort may occur, along with cognitive difficulties often referred to as "brain fog," which includes issues with memory, concentration, and mental clarity. Gastrointestinal symptoms such as nausea, bloating, and altered bowel habits are also frequent.

Other manifestations include abnormal sweating patterns, persistent headaches, visual disturbances like blurring or tunnel vision, and sensations of shakiness or anxiety. These symptoms are typically triggered or exacerbated by prolonged standing, exposure to heat, large meals, dehydration, or physical exertion.

POTS diagnosis

Diagnosis is primarily clinical but often requires a structured evaluation that begins with a detailed history and symptom assessment to identify hallmark features of orthostatic intolerance.

One of the key diagnostic steps includes measuring orthostatic vital signs, specifically monitoring heart rate and blood pressure as the patient transitions from a supine to a standing position. A 10-minute stand test or tilt table testing can further quantify postural heart rate changes and rule out orthostatic hypotension.

Additionally, clinicians must exclude other conditions that can mimic or exacerbate symptoms of POTS, including anemia, dehydration, hyperthyroidism, and cardiac arrhythmias. Depending on the clinical presentation, further diagnostic work-up may involve laboratory testing, electrocardiography (ECG), echocardiography, and specialized autonomic function testing to assess the integrity of the autonomic nervous system and rule out other forms of dysautonomia.

Treatment and management

There’s currently no cure for this condition, but symptoms can often be managed with a combination of lifestyle changes, medications, and sometimes medical devices. Treatment is individualized based on symptom severity and comorbid conditions.

Lifestyle modifications

Lifestyle modifications are a first-line approach to managing POTS. These include increasing fluid intake to two to three liters per day and adopting a high-salt diet (up to 8 to 10 grams daily) to help expand blood volume. Compression garments, such as abdominal binders or thigh-high stockings, improve venous return and can reduce blood pooling in the lower extremities.

Patients are encouraged to use physical counter-maneuvers, like leg crossing or squatting, to reduce symptoms during episodes of dizziness. Gradual reconditioning through exercise, starting with recumbent activities such as rowing, swimming, or biking, is recommended. Elevating the head of the bed at night can minimize blood pressure drops upon waking.

Medications

Medications are introduced based on individual response and may include beta-blockers like propranolol or atenolol to control tachycardia, and fludrocortisone to increase plasma volume. Midodrine, a vasoconstrictor, helps maintain blood pressure and reduce symptoms of orthostatic intolerance.

Pyridostigmine may support autonomic function in select cases, and ivabradine has been used off-label to reduce heart rate in refractory patients. Medications are typically titrated gradually to minimize side effects and optimize benefit.

Medical devices and monitoring

Devices such as heart rate and activity monitors can help patients track their symptoms and identify triggers. In patients with significant gastrointestinal symptoms or fluid losses, careful monitoring of electrolytes and volume status may be necessary.

Physical activity and exercise concerns

Exercise is a cornerstone of POTS management, but patients often face difficulty initiating and sustaining physical activity due to severe fatigue and orthostatic symptoms. A tailored, graduated exercise program can improve autonomic tone and increase blood volume.

Early stages should focus on non-upright activities (e.g., recumbent bike, resistance training in seated or supine positions). Over time, patients may tolerate upright exercises. Careful monitoring and pacing are essential, as overexertion can worsen symptoms. Collaborating with physical therapists familiar with dysautonomia can be helpful.

Self-care strategies

In addition to prescribed interventions, patients benefit from structured self-care. Tracking symptoms, identifying triggers, and noting responses to treatments can help guide ongoing management.

Maintaining hydration with electrolyte-enriched fluids and eating small, frequent meals can reduce postprandial hypotension. Avoiding known triggers such as heat, alcohol, and prolonged standing is crucial.

Patients may also benefit from mindfulness practices and cognitive-behavioral strategies to manage the anxiety and psychological impact of chronic illness. Peer support groups and educational resources empower patients to advocate for their needs and stay informed.

Summary

POTS is a multifaceted disorder that significantly impacts quality of life but can often be managed effectively with a personalized, multidisciplinary approach. Diagnosis is clinical, confirmed by heart rate changes on standing and exclusion of other causes.

Treatment includes lifestyle modification, pharmacologic therapy, physical rehabilitation, and supportive care. Early identification and comprehensive management can improve functional outcomes and symptom control, empowering patients to regain autonomy and improve their day-to-day well-being.

References

  • Vernino, S., Bourne, K.M., Stiles, L.E., et al. (2021). Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Autonomic Neuroscience. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC8455420/