---
title: Postural orthostatic tachycardia syndrome
description: What postural orthostatic tachycardia syndrome (POTS) is, why the heart rate rises and light-headedness appears on standing, how it differs from orthostatic hypotension and fainting, how it is recognised and treated, and when to call an ambulance.
type: disease
preset: sinus-tachycardia
aliases:
  - POTS
  - postural tachycardia syndrome
  - postural orthostatic tachycardia
  - orthostatic tachycardia
  - postural autonomic tachycardia
sources:
  - tier: guideline
    org: esc
    title: Рекомендации ЕОК по диагностике и лечению синкопальных состояний 2018
    year: 2019
    doi: 10.15829/1560-4071-2019-7-130-194
    url: https://doi.org/10.15829/1560-4071-2019-7-130-194
  - tier: guideline
    org: nice
    title: 'COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188)'
    year: 2024
    url: https://www.nice.org.uk/guidance/ng188
  - tier: guideline
    org: nice
    title: 'Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (NG206)'
    year: 2021
    url: https://www.nice.org.uk/guidance/ng206
  - tier: guideline
    org: nice
    title: Transient loss of consciousness ('blackouts') in over 16s (CG109)
    year: 2023
    url: https://www.nice.org.uk/guidance/cg109
  - tier: reference
    org: msd-manuals
    title: Orthostatic Hypotension
    year: 2024
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/orthostatic-hypotension
  - tier: reference
    org: msd-manuals
    title: Overview of the Autonomic Nervous System
    year: 2025
    url: https://www.msdmanuals.com/professional/neurologic-disorders/autonomic-nervous-system/overview-of-the-autonomic-nervous-system
  - tier: reference
    org: statpearls
    title: Postural Orthostatic Tachycardia Syndrome
    year: 2023
    url: https://www.ncbi.nlm.nih.gov/books/NBK541074/
  - tier: review
    title: '2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope'
    year: 2015
    doi: 10.1016/j.hrthm.2015.03.029
    url: https://doi.org/10.1016/j.hrthm.2015.03.029
sources_checked: 2026-10-13
review: null
---

Postural orthostatic tachycardia syndrome (POTS) is a condition in which, on standing up, the heart rate rises markedly and light-headedness, palpitations, weakness and other symptoms appear, while blood pressure hardly falls.<Cite n={[5, 7, 8]} /> Sitting or lying down eases the symptoms, although it does not always relieve them completely.<Cite n={[3, 6]} /> POTS can greatly limit daily life and reduce its quality.<Cite n={[7, 8]} /> According to the 2015 expert consensus of the Heart Rhythm Society (HRS), no deaths from POTS have been reported, although little is known about long-term outcomes.<Cite n={8} /> But similar symptoms can occur in other diseases, so a doctor needs to find the cause.<Cite n={[3, 8]} />

<Diagram name="postural-orthostatic-tachycardia-syndrome">
  <p slot="normal">
    The person stands up. Gravity makes some blood shift into the veins of the legs and trunk, and
    for a short time less blood returns to the heart.<Cite n={5} /> A reflex quickly brings blood
    pressure back to normal: the heart rate rises a little and the blood vessels tighten. In most
    people these changes are small and brief, and there are no symptoms.<Cite n={5} />
  </p>
  <p slot="disease">
    In POTS the heart rate rises markedly after standing up, while blood pressure falls little or
    not at all; light-headedness, palpitations and weakness appear.<Cite n={[5, 8]} /> In the view
    of the HRS experts, in some people the veins of the legs and abdomen do not tighten enough and
    more blood pools in them, and the heart has to make up for this.<Cite n={8} /> This is only one
    of the mechanisms described: why POTS develops is not fully understood.<Cite n={[5, 7]} />
  </p>
</Diagram>

## Why it happens

<Patient>

Why POTS develops is not fully understood.<Cite n={[5, 7]} /> The HRS experts describe several mechanisms that often occur together in the same person: a problem with the autonomic nerves, a reduced blood volume, overactivity of the sympathetic nervous system, deconditioning (loss of physical fitness) and heightened attention to bodily sensations.<Cite n={8} /> The StatPearls review names similar mechanisms, including a possible role of the immune system.<Cite n={7} />

Anxiety is common in POTS, but according to the studies cited by HRS, it is not anxiety that makes the heart rate rise on standing, but an underlying problem in how the body works.<Cite n={8} />

POTS most often affects young women.<Cite n={[7, 8]} /> It is common in people with chronic fatigue syndrome (myalgic encephalomyelitis).<Cite n={[3, 8]} /> POTS has also been described after COVID-19 as one sign of a disturbance of the autonomic nervous system; why this happens is unknown.<Cite n={6} />

</Patient>

<Student>

The mechanisms below are the view of the HRS experts.<Cite n={8} /> In the neuropathic form, the authors believe that impaired sympathetic tone reduces venoconstriction, leading to venous pooling in the lower limbs and splanchnic beds; a high cardiac output is needed to compensate. In some patients the autonomic denervation might be autoimmune.<Cite n={8} /> The ESC guidelines mention reported cases of autoantibodies to adrenergic receptors in orthostatic hypotension (OH) and POTS, but consider that this needs further study.<Cite n={1} />

Blood volume is reduced in some patients. In the hyperadrenergic form the rise in heart rate is similar to that in other patients, but symptoms of sympathetic activation are prominent: palpitations, anxiety and tremor.<Cite n={8} /> Deconditioned patients have reduced left ventricular mass, stroke volume and blood volume, which improve with exercise training; whether deconditioning is the primary cause or a secondary phenomenon is unclear.<Cite n={8} />

</Student>

## Symptoms

<Patient>

The main symptoms appear on standing: light-headedness, palpitations, shakiness, general weakness, blurred vision, poor exercise tolerance and tiredness.<Cite n={[5, 8]} /> Many people are troubled by difficulty thinking and concentrating, often called "brain fog".<Cite n={[5, 8]} />

There can also be symptoms that do not depend on posture: bloating, nausea, diarrhoea and abdominal pain, as well as general ones such as tiredness, poor sleep, headache and migraine.<Cite n={[7, 8]} /> Symptoms are often made worse by dehydration, heat, alcohol and exercise.<Cite n={8} />

People with POTS sometimes faint, but feeling close to fainting is much more common. POTS and [vasovagal syncope](../vasovagal-syncope/) can occur in the same person.<Cite n={8} />

</Patient>

<Student>

Sources word the heart rate thresholds differently. These are criteria for the clinician performing the test, not for self-testing:

- ESC (IIa, C): POTS should be considered likely when there is an orthostatic heart rate increase of more than 30 bpm, or to more than 120 bpm, within 10 minutes of active standing in the absence of OH, with reproduction of the spontaneous symptoms.<Cite n={1} />
- HRS: frequent symptoms on standing, an increase in heart rate of ≥30 bpm when moving from a recumbent to a standing position held for more than 30 seconds (≥40 bpm at 12 to 19 years of age), and the absence of orthostatic hypotension (a fall in systolic blood pressure of more than 20 mm Hg).<Cite n={8} />
- StatPearls: in adults, an increase of ≥30 bpm within the first 10 minutes of standing or head-up tilt in the absence of OH.<Cite n={7} /> MSD: a heart rate of ≥120 bpm or an increase of ≥30 bpm when moving from supine to standing.<Cite n={5} />

The ESC lists POTS, together with classical, initial and delayed OH and orthostatic vasovagal syncope, among the cardiovascular causes of orthostatic intolerance.<Cite n={1} /> In OH blood pressure falls excessively on assuming an upright position (by consensus definition, a drop of more than 20 mm Hg systolic, more than 10 mm Hg diastolic, or both), whereas in POTS there is little or no fall in blood pressure.<Cite n={5} /> MSD links a marked rise in heart rate to hypovolaemia or, if symptoms develop without hypotension, to POTS.<Cite n={5} /> The tachycardia of POTS is sinus tachycardia.<Cite n={8} />

</Student>

## How it is diagnosed

<Patient>

The doctor asks in detail how long the symptoms have been present, what makes them better or worse, how they affect daily life, what might have triggered them and whether there are illnesses in the family.<Cite n={8} /> Then the doctor examines you, records an [ECG](../../diagnostic/ecg/) and measures heart rate and blood pressure lying down and standing.<Cite n={[2, 8]} /> To check for POTS you need to stand for longer than when checking for orthostatic hypotension.<Cite n={[1, 2]} />

Some people have blood tests and thyroid tests, [Holter monitoring](../../diagnostic/holter-monitoring/), [echocardiography](../../diagnostic/echocardiography/) and an exercise test. These tests help make sure heart disease or another cause of the symptoms is not missed; in the view of the HRS experts, for most people this small set of tests is enough to make the diagnosis and start treatment.<Cite n={8} />

If the standing test is normal but POTS is strongly suspected, a tilt test may help, because heart rate and blood pressure can be watched for longer.<Cite n={[1, 8]} /> How a tilt test is done is described in the article on [vasovagal syncope](../vasovagal-syncope/).

</Patient>

<Student>

HRS recommends a complete history and physical examination with orthostatic vital signs and a 12-lead ECG for all patients being assessed for POTS (I). A complete blood count and thyroid function studies can be useful in selected patients (IIa, E); a 24-hour Holter monitor, detailed autonomic testing, transthoracic echocardiography, tilt-table testing and exercise stress testing may be considered in selected patients (IIb, E).<Cite n={8} /> If symptoms do not resolve or markedly improve, HRS suggests a more extensive evaluation at a centre experienced in autonomic testing of patients with POTS.<Cite n={8} />

ESC: a tilt test should be considered in patients with suspected POTS (IIa, B); POTS should be considered likely if the test reproduces the symptoms together with the characteristic haemodynamic changes.<Cite n={1} /> For people with postural symptoms after COVID-19, NICE (NG188) advises a 3-minute active stand test for OH, or 10 minutes if postural tachycardia syndrome is suspected.<Cite n={2} />

</Student>

## How it is treated

<Patient>

POTS is not easy to treat: in the view of the HRS experts, no treatment works for everyone, and several approaches often have to be combined.<Cite n={8} /> It helps when a team is involved: doctors, psychologists, nurses, and physical and rehabilitation therapists.<Cite n={8} />

HRS advises starting without medicines.<Cite n={8} /> The doctor may review medicines that can make symptoms worse; do not change or stop them on your own. The doctor may suggest drinking more fluid and adding more salt to food to increase blood volume; how much is for the doctor to decide. Compression garments reduce pooling of blood in the veins.<Cite n={8} />

Regular exercise matters, with the load increased gradually and under the supervision of a specialist: aerobic exercise and exercises for the thigh muscles. At first, exercise is done while not upright, for example on a rowing machine, a recumbent bike or in a swimming pool, so that the upright position puts less strain on the heart.<Cite n={8} />

If this is not enough, the doctor may choose medicines aimed at a specific problem.<Cite n={8} /> For people with chronic fatigue syndrome, NICE advises that such medicines should only be prescribed or overseen by a healthcare professional with expertise in this area, and that people whose symptoms are severe or worsening, or in whom another condition may be the cause, should be referred to a specialist.<Cite n={3} />

POTS usually lasts a long time. The HRS experts consider that it usually improves eventually, but its course differs from person to person.<Cite n={8} />

</Patient>

<Student>

The HRS treatment recommendations are an expert consensus: few treatments have been tested in randomised clinical trials.<Cite n={8} /> A regular, structured and progressive exercise programme can be effective (IIa, B-R); a multidisciplinary approach is IIb, E.<Cite n={8} />

HRS suggests drug treatment if non-pharmacological measures are not completely effective, targeted at specific problems. It discusses agents that boost sodium retention and expand plasma volume, vasoconstrictors, heart-rate-lowering agents and, in patients with prominent hyperadrenergic features, central sympatholytics; all these recommendations are class IIb.<Cite n={8} /> The decision about medicines is made by the doctor.

HRS recommends against (class III) drugs that block the noradrenaline reuptake transporter (they can worsen symptoms), regular intravenous saline infusions and, for routine use, invasive interventions, including radiofrequency sinus node modification.<Cite n={8} />

</Student>

## When to call an ambulance

People with POTS sometimes faint, but fainting can also be caused by heart disease, so it is important to know the warning signs.<Cite n={[1, 4]} /> What to do when someone faints is described in the article on [vasovagal syncope](../vasovagal-syncope/).

**Call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK)** if:

- the person has lost consciousness and does not fully come round;<Cite n={4} />
- the faint happened during physical exertion or while lying down;<Cite n={[1, 4]} />
- the faint came straight after a sudden onset of a fast heartbeat;<Cite n={1} />
- new chest discomfort, breathlessness, abdominal pain or headache appeared together with the faint.<Cite n={1} />

**See a doctor without delay** if, after a loss of consciousness, there is an abnormal ECG, heart failure, a heart murmur or new or unexplained breathlessness, or if a family member died suddenly of a heart cause before the age of 40 or there is an inherited heart condition.<Cite n={4} />

<Quiz />