Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is a chronic condition characterized by intolerance to changes from lying down to standing. The condition is defined by an abnormally large increase in heart rate upon standing, without a simultaneous drop in blood pressure¹. The underlying mechanism is believed to be a dysregulation of the autonomic nervous system, particularly a failure to maintain adequate cerebral blood flow.

POTS is often divided into two main categories:

• Primary (idiopathic): cause is unknown

• Secondary: occurs as a consequence of another underlying disease or condition

Prevalence

The prevalence of POTS has not yet been well mapped in large population studies, but clinical experience suggests that between 0.2% and 1% of the U.S. population is affected – equivalent to 1–3 million people². The condition is far more common in women in their teens and young adulthood, and less frequent in men and older individuals³. A large survey of over 4,800 POTS patients showed that the average age of onset was around 14 years³.

Clinical Picture

POTS is a complex, chronic disorder of the autonomic nervous system. The hallmark symptom is orthostatic intolerance – symptoms that appear when the patient stands upright but resolve when lying down. The most characteristic finding is a sustained increase in heart rate of at least 30 beats per minute (or ≥40 in adolescents) within 10 minutes of standing, without a concurrent drop in blood pressure³.

Common symptoms include:

• Dizziness

• Palpitations (rapid heartbeat)

• Tremors and generalized weakness

• Headache and concentration difficulties

• Fatigue and exhaustion

• Nausea, abdominal pain, and other gastrointestinal discomfort

• Visual disturbances

Symptoms must persist for at least three months, and there should be no other explanation for the elevated heart rate³.

Common Comorbidities

Although many cases of POTS are idiopathic, the condition frequently occurs alongside other disorders. The most common associated condition is myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Several studies suggest that POTS may be a trigger for ME/CFS, and that treating POTS can reduce disabling fatigue⁴.

Other commonly associated conditions include:

• Vasovagal syncope (neurocardiogenic syncope)

• Fibromyalgia (symptom relief reported with POTS treatment)

• Irritable bowel syndrome (IBS)

• Ehlers–Danlos syndrome (EDS) – particularly due to connective tissue weakness in blood vessels causing pooling in the lower extremities⁵

Additional reported comorbidities:

• Addison’s disease

• Anemia

• Diabetes

• Guillain–Barré syndrome and systemic lupus erythematosus

• Cardiovascular atrophy

• Previous gastric bypass surgery

• Neurological lesions

• Syringomyelia

• Hyperthyroidism or other endocrine disease

• Tumors affecting the autonomic nervous system

Treatment and Medical Management

Pharmacological therapy in POTS is often aimed at increasing blood volume and regulating heart rate.

Common medications include:

• Fludrocortisone: Increases sodium retention and blood volume, improving blood pressure

• Beta-blockers: Reduce excessive heart rate

• Midodrine: Increases peripheral blood pressure through vasoconstriction, often combined with beta-blockers

• SSRIs: Sometimes used to regulate autonomic function and stabilize blood pressure

Treatment must often be individualized, and it is common to try several medications before optimal effect is achieved.

Diagnosis and Testing

POTS is a difficult diagnosis to establish. Many patients have had symptoms for over a year before diagnosis is made. A thorough evaluation to exclude differential diagnoses is essential.

Tilt table test is the gold standard:

• The patient is strapped to a motorized table tilted to ~60°

• Pulse and blood pressure are measured in supine and standing positions

• The test lasts up to 40 minutes or until fainting occurs⁵

• Often combined with transcranial Doppler ultrasound to assess changes in cerebral blood flow

It is crucial to rule out serious underlying conditions such as Addison’s disease, Lyme disease, hyperthyroidism, and major neurological disorders.

Causes and Triggers

The causes of POTS are still unclear but are thought to involve autonomic dysfunction related to regulation of blood flow, particularly to the brain. Many develop symptoms during adolescence, especially boys, and some experience improvement with age.

Other known triggers include:

• Prior viral or bacterial infection (e.g., pneumonia)

• Physical trauma (e.g., car accident)

• Pregnancy (common in women with POTS onset postpartum)

Systemic Impact

POTS can affect several organ systems once other causes are excluded, mainly due to hypoperfusion of blood to the upper body and brain.

Common systemic symptoms include:

• Cognitive impairment, poor concentration, and “brain fog”

• Sleep disturbances and depression

• Abdominal discomfort, nausea, and altered bowel function (both constipation and diarrhea)

• General fatigue and malaise

This combination often leads to a dual diagnosis of chronic fatigue syndrome alongside POTS.

Treatment of POTS

Postural orthostatic tachycardia syndrome (POTS) often requires a multidisciplinary approach. A large study by Junghans-Rutelonis and colleagues emphasized that a combination of pharmacological therapy, physiotherapy, cognitive behavioral therapy, psychoeducation, and integrative medicine yields the best results in children with POTS¹.

Management strategies include:

Dietary recommendations

Patients are encouraged to increase fluid intake to at least 2 liters daily, combined with a high salt intake of 3–5 grams per day. This helps increase blood volume and reduce orthostatic symptoms.

Non-pharmacological treatment

One of the best-documented acute interventions in POTS is volume expansion. A study by Jacob and colleagues showed that intravenous infusion of 1 liter of saline over 1 hour immediately reduced orthostatic tachycardia. The effect is short-term but clearly demonstrates the link between blood volume and symptom burden.

Pharmacological treatment

When non-pharmacological measures are insufficient, medications may be considered. There is no universal drug therapy for POTS – choice depends on underlying cause and symptom profile.

Common medications:

• Fludrocortisone: Increases sodium and fluid retention and sensitizes α-adrenergic receptors; used mainly for volume expansion

• Beta-blockers: Effective in hyperadrenergic POTS with significantly elevated heart rate

• SSRIs: Enhance neural communication and improve vasoconstrictive reflex when standing, reducing venous pooling and improving orthostatic tolerance

• NRIs (noradrenaline reuptake inhibitors): May provide additional relief in patients already using SSRIs

Since POTS often affects daily function, it is essential to involve a multidisciplinary team – including physiotherapists, occupational therapists, clinical psychologists, social workers, and, when necessary, legal advisors.

Physiotherapeutic Management

Physiotherapy in POTS

Physiotherapy in POTS has two main goals: patient education and functional training. Treatment must be individualized and adapted to disease progression, medication use, and the degree of orthostatic intolerance.

Patient Education

Education should cover:

• Basic understanding of respiratory physiology and control of breathing patterns

• The relationship between breathing, stress, and anxiety – and how these influence symptoms such as dyspnea and dizziness

Breathing Technique and Retraining

• Breath control in rest and during activity: Learning to regulate breathing rhythm under exertion

• Controlled pause technique: Applied to counteract hyperventilation and reduce sympathetic activation

Exercise and Physical Activity

Physical exercise is a fundamental part of POTS management, especially in patients with deconditioning. Exercise leads to:

• Increased blood volume and stroke volume

• Improved vascular tone and peripheral circulation

• Adaptations in baroreflex and autonomic control

Challenges: Many patients experience worsening of symptoms after activity and therefore avoid exercise. Training must be individualized, start at low intensity, and progress gradually. Some patients may not tolerate exercise until pharmacological treatment has stabilized heart rate and blood pressure.

Types of exercise that can be included:

• Aerobic training: Low-intensity cycling, rowing, or swimming

• Strength training: Isometric exercises, leg press, and other closed-chain movements

• Functional training: Focus on joint stability, coordination, and neuromuscular control

Practical Adjustments in Training Programs

1. Positioning:Studies show that many POTS patients cannot adequately increase stroke volume during upright activity, leading to symptoms such as dizziness, dyspnea, and weakness. Therefore, training should initially be performed in horizontal positions:

2. Supine leg press

3. Seated rowing

4. Reclined cycling

5. Swimming

6. Intensity and Test Selection:Maximal heart rate testing is often impractical. Submaximal tests such as the incremental shuttle walk test or cycle ergometry are good alternatives. For patients on beta-blockers, the Borg Rating of Perceived Exertion (RPE) scale is recommended to assess training intensity.

Physiotherapy in POTS requires patience, careful clinical assessment, and close multidisciplinary collaboration. The goal is to reduce symptoms, increase tolerance to activity, and improve long-term quality of life.

References

1. Sebastian SA, Co EL, Panthangi V, Jain E, Ishak A, Shah Y, Vasavada A, Padda I. Postural orthostatic tachycardia syndrome (POTS): an update for clinical practice. Current Problems in Cardiology. 2022 Dec 1;47(12):101384.

2. Dr Blair Grubb. What is POTS? Available from: https://www.youtube.com/watch?v=ch6ipV3M4yo&feature=youtu.be (accessed 05.07.2025).

3. Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP. 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. 2021 Nov 1;235:102828.

4. Raj SR, Fedorowski A, Sheldon RS. Diagnosis and management of postural orthostatic tachycardia syndrome. CMAJ. 2022 Mar 14;194(10):E378–85.

5. Agarwal A, Garg R, Ritch A, Sarkar P. Postural orthostatic tachycardia syndrome. Postgrad Med J. 2007 Mar 20;83:478–480.

6. Wallman D, Weinberg J, Hohler AD. Ehlers–Danlos syndrome and postural tachycardia syndrome: a relationship study. Journal of the Neurological Sciences. 2014 May 15;340(1–2):99–102.

7. Grubb BP, Kosinski DJ, Boehm K, Kip K. The Postural Orthostatic Tachycardia Syndrome: A Neurocardiogenic Variant Identified During Head-Up Tilt Table Testing. Pacing and Clinical Electrophysiology. 1997;20(9):2205–12.

8. Junghans-Rutelonis AN, Postier A, Warmuth A, Schwantes S, Weiss KE. Pain Management In Pediatric Patients With Postural Orthostatic Tachycardia Syndrome: Current Insights. Journal of Pain Research. 2019;12:2969.

9. Reilly CC, Floyd SV, Lee K, Warwick G, James S, Gall N, Rafferty GF. Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): the impact of a physiotherapy intervention. Autonomic Neuroscience. 2020 Jan 1;223:102601.

10. De Wandele I, Low D, Rowe P, Simmonds JV. Exercise guidelines for postural tachycardia syndrome. In: Postural Tachycardia Syndrome: A Concise and Practical Guide to Management and Associated Conditions. 2021:207–15.

11. Mayo Clinic. Living with POTS. Available from: https://www.youtube.com/watch?v=ChJq1ITffCs (accessed 05.07.2025).