Postural orthostatic tachycardia syndrome (POTS) for health professionals

On this page

• What is POTS?
• Recognising POTS
• Diagnosing POTS
• Managing POTS
• POTS and cardiovascular health
• POTS and post-viral illness
• Multidisciplinary care
• When to refer
• Resources

What is POTS?

Postural orthostatic tachycardia syndrome (POTS) is a disorder of the autonomic nervous system, characterised by symptoms of orthostatic intolerance and an excessive increase in heart rate when standing.¹ In adults, POTS is diagnosed by a sustained increase in heart rate of at least 30 beats per minute on an orthostatic challenge test (an Active Stand Test or Head Up Tilt Test), in the absence of sustained orthostatic hypotension, together with symptoms of orthostatic intolerance. In adolescents aged 12–19 years, the increase in heart rate is at least 40 beats per minute.^2,3

POTS can affect people across the lifespan but is more common in women of childbearing age. Symptoms may fluctuate substantially over time, with periods of relative stability and episodes of significant exacerbation.1 The 2026 State-of-the-Art Review provides a contemporary overview of POTS, including its clinical presentation, diagnosis, investigation and management, and highlights the importance of multidisciplinary care.¹

Recognising POTS

Consider POTS in people with recurrent symptoms that are triggered or worsened by standing and improve with sitting or lying down.

Common symptoms include:

• palpitations or awareness of a rapid heartbeat
• light-headedness or dizziness
• pre-syncope or syncope
• fatigue
• exercise intolerance
• weakness or tremulousness
• difficulty concentrating or cognitive dysfunction
• headache
• shortness of breath
• chest discomfort
• nausea and other gastrointestinal symptoms
• heat intolerance
• symptoms that worsen with prolonged standing.

Symptoms can be highly variable and can be orthostatic and non-orthostatic in nature. Some people experience relatively mild symptoms, whereas others develop substantial limitations in physical activity, education, employment and participation in everyday activities.^1–3

How is POTS diagnosed?

POTS is a clinical diagnosis based on the patient's history, physical examination and assessment of the cardiovascular response to standing with an orthostatic challenge test.^1–3

Assessing the orthostatic response

An active stand test can usually be performed in primary care or other clinical settings.^1,2

Points for consideration:^1,2

1. Testing should ideally be undertaken in the morning in a temperature controlled environment. Any medications that could impact the results should be held for testing if safe to do so.
2. Allow the patient to rest supine before posture change for at least 5 minutes.
3. Measure heart rate and blood pressure at baseline.
4. Ask the patient to stand and lean against a bed or the wall to minimise enhancing venous return via activation of calf muscles.
5. Repeat heart rate and blood pressure measurements every minute during the 10 minutes of standing.
6. Record the patient's symptoms throughout the assessment.

In adults, POTS is characterised by:

A sustained increase (2 consecutive measurements that are one minute apart) in heart rate of ≥30 beats per minute during 10 minutes of standing, without sustained orthostatic hypotension, accompanied by symptoms of orthostatic intolerance. In adolescents, the heart rate increase should be ≥40 beats per minute.^2,3

The heart rate response should be interpreted in the context of the clinical presentation. A single negative assessment does not necessarily exclude POTS when clinical suspicion remains high, as such repeat assessment or specialist evaluation may be appropriate. ²

A tilt-table test is not routinely required for diagnosis but may be useful in select patients where the diagnosis remains uncertain or in instances of inconclusive active stand measurements.³

Investigations

Investigations should be guided by the clinical presentation and used to identify alternative or contributing causes of tachycardia and orthostatic symptoms.1–3

Depending on the presentation, investigations may include:

• 12-lead ECG
• full blood count
• electrolytes and renal function
• thyroid function tests
• iron studies
• medication review
• ambulatory ECG monitoring (Holter monitor) where an arrhythmia is suspected
• echocardiography to rule out structural causes.

Additional investigations or specialist autonomic testing may be appropriate in selected patients.

Wearable devices can provide useful information about heart-rate patterns but should not be used in isolation to establish a diagnosis of POTS.¹

What else should be considered?

An increase in heart rate on standing is not specific to POTS.

Consider other causes of orthostatic tachycardia or similar symptoms, including:^1–3

• anaemia or iron deficiency
• thyroid and other endocrine disorders
• medication effects
• acute illness or infection
• cardiac arrhythmia
• structural heart disease

A medication review is an important component of assessment, particularly where medicines may affect heart rate, blood pressure or circulating blood volume.

Managing POTS

There is no single treatment that is effective for everyone with POTS.

Management should be individualised according to symptoms, cardiovascular profile, functional capacity, comorbidities and patient preferences.1–3

Education and self-management

Education is an important component of POTS management.

Patients should understand the relationship between posture, symptoms and heart rate and identify individual factors that worsen or improve their symptoms.

Treatment strategies^1–3 include:

• fluid intake of 2–3 litres per day, where clinically appropriate
• individualised increases in dietary salt, commonly targeting approximately 3,000–4,000 mg sodium per day where clinically appropriate
• using medical grade compression wear
• avoiding or minimising prolonged standing where possible
• reducing exposure to excessive heat
• using physical counter-manoeuvres where appropriate
• maintaining regular physical activity within individual tolerance
• developing strategies to manage symptom exacerbations.

Exercise and physical rehabilitation

Exercise programs should be individualised according to baseline functional capacity, symptom severity and comorbidities. For people with significant orthostatic intolerance or exercise limitation, an initial program may involve recumbent or semi-recumbent exercise before gradually progressing towards upright exercise as tolerated.^1–3

A physiotherapist, accredited exercise physiologist or other clinician experienced in exercise rehabilitation should be engaged to assist with developing and progressing an appropriate program. Exercise should be introduced gradually and monitored according to symptoms and functional response.^1-3

Pharmacological treatment

Pharmacological treatment may be considered when symptoms remain troublesome despite appropriate non-pharmacological management.1–3

Depending on the clinical presentation, medicines used in POTS may include:1–3

• midodrine
• ivabradine
• fludrocortisone
• beta blockers
• pyridostigmine
• other specialist-directed therapies.

Medicines used to treat POTS in Australia are off-label and may be cost prohibitive for some people.

POTS and cardiovascular health

POTS is a disorder of autonomic cardiovascular regulation and is not, in itself, evidence of structural heart disease. However, people with POTS may experience cardiovascular symptoms including palpitations, chest discomfort, breathlessness, dizziness and exercise intolerance. These symptoms should be assessed in their clinical context and should not automatically be attributed to POTS. Healthcare professionals should continue to assess cardiovascular risk and investigate symptoms suggestive of other cardiac conditions when clinically indicated.^1–3

New or unexplained chest pain, sustained arrhythmia, haemodynamic instability or concerning syncope should be appropriately investigated rather than attributed to POTS without assessment.¹

POTS and post-viral illness

POTS may develop following an acute illness or infection. POTS has been increasingly recognised following COVID-19 infection and within the broader spectrum of post-acute sequelae of SARS-CoV-2 infection and is a recognised presentation of Long COVID.^4,5

POTS has also been reported following COVID-19 vaccination, although evidence for a causal relationship remains limited. ^4-6

However, POTS can occur following a range of potential triggers including hormonal change, viral infection, concussion, and traumatic events and may also develop without an identifiable precipitating factor. ¹

Multidisciplinary care

POTS can affect multiple aspects of physical and psychosocial functioning. Management may therefore involve several healthcare professionals.¹

Depending on the individual's needs, this may include:

• general practitioners
• cardiologists
• neurologists
• specialist nurses
• physiotherapists
• accredited exercise physiologists
• occupational therapists
• pharmacists
• dietitians
• psychologists and other mental health professionals.

Primary care can play an important role in coordinating care, monitoring symptoms, reviewing medications, managing cardiovascular risk factors and facilitating appropriate specialist and allied health referrals.

When should I refer?

Consider specialist assessment when:^1–3

• the diagnosis is uncertain
• there is unexplained or recurrent syncope
• an arrhythmia is suspected
• structural heart disease is suspected
• symptoms are severe or progressively worsening
• there is substantial functional impairment
• symptoms remain troublesome despite initial management
• pharmacological treatment requires specialist input
• complex comorbidities are present
• specialised autonomic testing is required.

Urgent assessment is appropriate for symptoms suggestive of an acute or serious cardiovascular condition, including new or unexplained chest pain, sustained arrhythmia, haemodynamic instability or concerning syncope.