Postural Orthostatic Tachycardia Syndrome (POTS)
Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system that causes symptoms such as dizziness, palpitations, fatigue and brain fog when standing. Learn how POTS is diagnosed, why it develops and the evidence-based approaches available to improve symptoms and quality of life.
This information is intended for educational purposes and should not replace professional medical advice. If you have new, severe or worsening symptoms, always seek advice from your GP or specialist healthcare team.
KEY FACTS
✔ Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system that affects how the body regulates heart rate and blood circulation when standing.
✔ It is diagnosed when the heart rate increases by 30 beats per minute or more within 10 minutes of standing (40 beats per minute in adolescents), without a significant fall in blood pressure, together with symptoms lasting at least three months.
✔ Common symptoms include dizziness, palpitations, fatigue, brain fog, exercise intolerance and light-headedness, typically improving when lying down.
✔ POTS often develops after a viral infection (including COVID-19), pregnancy, surgery or prolonged inactivity, although no clear trigger is identified in many people.
✔ The condition frequently occurs alongside Long COVID, ME/CFS, joint hypermobility, migraine and mast cell-related symptoms, making a comprehensive assessment important.
✔ There is currently no single cure, but many people experience meaningful improvement through a combination of education, lifestyle measures, rehabilitation and, where appropriate, medication.
✔ Management should always be individualised, as the biological mechanisms contributing to POTS vary from one person to another.
UNDERSTANDING THE CONDITION
Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder affecting the autonomic nervous system, the part of the nervous system responsible for automatically regulating essential body functions such as heart rate, blood pressure, breathing and digestion.
When a healthy person stands up, gravity causes blood to pool temporarily in the legs and abdomen. The autonomic nervous system rapidly adjusts blood vessel tone and heart rate to maintain blood flow to the brain. In people with POTS, this automatic adjustment is disrupted. As a result, the heart beats much faster than normal when standing in an attempt to maintain adequate circulation, often leading to dizziness, palpitations, fatigue and other symptoms.
Although the defining feature of POTS is an excessive increase in heart rate on standing, the condition affects far more than the cardiovascular system. Many people also experience difficulties with concentration, sleep, digestion, temperature regulation and exercise tolerance because the autonomic nervous system influences multiple organs throughout the body.
POTS is increasingly recognised worldwide, particularly following the COVID-19 pandemic, which has highlighted autonomic dysfunction as one possible consequence of viral illness. However, POTS has been recognised for many years and can occur in people who have never had COVID-19. Common triggers include viral infections, pregnancy, surgery, trauma or periods of prolonged inactivity, although many patients cannot identify a specific event preceding the onset of symptoms.
One of the challenges of POTS is that its symptoms often overlap with those of other conditions, including anxiety disorders, chronic fatigue syndrome (ME/CFS), Long COVID and thyroid disease. This contributes to delays in diagnosis for many people. Fortunately, POTS is defined by objective physiological changes that can be measured during standing tests, allowing an accurate diagnosis when appropriate assessment is undertaken.
Importantly, POTS is not a single disease with a single cause. Current research suggests that several biological mechanisms can contribute to the condition, often overlapping within the same individual. Understanding these mechanisms helps explain why treatment needs to be personalised rather than following a one-size-fits-all approach.
COMMON SYMPTOMS
People with POTS experience a wide range of symptoms that typically become worse when standing and improve on sitting or lying down. Symptoms vary considerably between individuals, and not everyone experiences the same combination or severity.
Common symptoms include:
Palpitations or a rapid heartbeat when standing
Dizziness or light-headedness
Feeling faint or episodes of near-fainting (presyncope)
Fatigue and reduced physical stamina
Exercise intolerance
Brain fog, poor concentration or memory difficulties
Blurred vision or visual disturbances on standing
Tremulousness or shaking
Shortness of breath
Headaches or migraine
Nausea, bloating or altered bowel habits
Sleep disturbance
Heat intolerance
Excessive or reduced sweating
Purple or mottled discolouration of the legs after standing (acrocyanosis)
Many people notice that symptoms worsen during hot weather, after prolonged standing, following large meals, during menstruation, with dehydration or after alcohol consumption. Recognising these patterns is often helpful during assessment and can guide personalised management strategies.
CAUSES, MECHANISMS AND DIAGNOSIS
Why Does It Happen?
One of the most important things to understand about Postural Orthostatic Tachycardia Syndrome (POTS) is that it is not a single disease with a single cause. Instead, it describes a pattern of abnormal cardiovascular and autonomic responses that can develop through several different biological mechanisms. Many people have features of more than one mechanism, which is why symptoms and treatment responses vary considerably from one person to another.
At Rowan Health, we believe understanding these mechanisms is fundamental to developing an individualised management plan rather than applying the same advice to everyone.
The body's automatic "standing system"
Every time you stand up, gravity causes approximately 500–800 ml of blood to move into the legs and abdomen. In healthy individuals, the autonomic nervous system immediately compensates by narrowing blood vessels, slightly increasing heart rate and maintaining blood flow to the brain.
In POTS, this automatic system becomes less effective. To compensate, the heart beats much faster than normal in an attempt to maintain adequate circulation. While this response helps preserve blood flow, it can also produce many of the symptoms associated with the condition, including dizziness, palpitations, fatigue and cognitive difficulties.
Several biological mechanisms may contribute
Current research suggests that several overlapping mechanisms may contribute to POTS.
Impaired blood vessel regulation (Neuropathic POTS)
In some people, the nerves responsible for tightening blood vessels in the legs and abdomen do not function efficiently. Blood pools in the lower body when standing, reducing the amount returning to the heart. To compensate, heart rate increases significantly.
People with this pattern may notice:
marked dizziness when standing
cold or discoloured legs
symptoms improving when lying down
increased benefit from compression garments.
Increased sympathetic ("adrenaline") activity
Others develop excessive activation of the sympathetic nervous system, sometimes referred to as the body's "fight or flight" response. This does not mean symptoms are psychological. Rather, the body produces an exaggerated physiological response to standing.
This pattern may be associated with:
marked palpitations
tremor
feeling shaky
heightened awareness of heartbeat
anxiety-like sensations caused by increased adrenaline activity.
Reduced circulating blood volume
Some individuals appear to have a lower circulating blood volume than expected. With less blood available to circulate, the heart must work harder when standing to maintain blood flow to the brain.
This helps explain why increasing fluid intake and, where appropriate, dietary salt can improve symptoms in many patients.
Post-infectious and immune-related mechanisms
POTS sometimes develops after viral illnesses, including COVID-19, suggesting that infections may trigger changes affecting autonomic nervous system function in susceptible individuals.
Researchers are investigating several possible immune-mediated mechanisms, although these remain an active area of research. At present, no single laboratory test can confirm an immune cause, and routine antibody testing is not recommended outside specialist settings.
Physical deconditioning
For some people, prolonged illness or reduced activity contributes to physical deconditioning. Reduced muscle strength, smaller blood volume and decreased cardiovascular fitness can all worsen orthostatic symptoms.
Importantly, this does not mean that POTS is "caused by being unfit". Instead, reduced activity often develops because symptoms make exercise difficult, creating a cycle in which inactivity further aggravates the condition. Carefully supervised rehabilitation aims to break this cycle gradually.
Conditions commonly associated with POTS
POTS frequently occurs alongside other medical conditions. Recognising these associations is important because they may influence both assessment and management.
Long COVID
Many people with Long COVID experience symptoms of autonomic dysfunction similar to those seen in POTS. Persistent dizziness, palpitations, exercise intolerance and brain fog following COVID-19 infection should prompt consideration of orthostatic intolerance as part of the assessment.
ME/CFS
POTS and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) frequently overlap.
One particularly important distinction is post-exertional malaise (PEM). Unlike the immediate worsening experienced during exercise in many people with POTS, PEM causes a delayed worsening of symptoms 24 to 72 hours after physical or mental exertion.
Recognising PEM is essential because it changes how rehabilitation should be approached. Standard exercise programmes may not be appropriate for people experiencing post-exertional malaise.
Joint hypermobility
Generalised joint hypermobility and hypermobile Ehlers-Danlos syndrome (hEDS) occur more frequently in people with POTS than in the general population. Although the exact relationship is still being investigated, connective tissue differences may contribute to blood pooling and altered vascular support.
Migraine
Migraine is another common comorbidity. Some medications prescribed for POTS may also help prevent migraine, allowing treatment to address more than one condition simultaneously.
Mast cell-related symptoms
Some people experience episodes of flushing, hives, gastrointestinal symptoms or reactions triggered by heat, foods or environmental factors alongside POTS.
Research into mast cell activation remains ongoing, and specialist assessment is recommended where these symptoms are prominent rather than assuming a diagnosis based on symptoms alone.
How It Is Diagnosed
Diagnosing POTS involves combining a detailed clinical history with objective measurements of heart rate and blood pressure during changes in posture. There is currently no single blood test or scan that confirms the diagnosis.
Clinical assessment
Your clinician will begin by exploring:
when symptoms started
factors that trigger or worsen symptoms
how symptoms affect work, education and daily activities
previous infections, surgery, pregnancy or prolonged inactivity
associated symptoms affecting digestion, sleep, headaches or temperature regulation
possible overlapping conditions such as Long COVID, ME/CFS, joint hypermobility or migraine.
The Active Stand Test
The principal diagnostic test is the Active Stand Test.
After resting quietly while lying down, heart rate and blood pressure are measured before standing and again over the following ten minutes.
In adults, a sustained increase in heart rate of 30 beats per minute or more (40 beats per minute in adolescents), without a significant fall in blood pressure, supports the diagnosis when symptoms have been present for at least three months.
Additional investigations
Blood tests and other investigations are usually performed to exclude conditions that may produce similar symptoms, including:
anaemia
thyroid disorders
vitamin deficiencies
electrolyte abnormalities
diabetes
cardiac rhythm disorders when appropriate.
If the diagnosis remains uncertain, a specialist may recommend a tilt-table test, which provides more detailed assessment of cardiovascular responses during controlled changes in posture.
Looking beyond the diagnosis
A diagnosis of POTS is only the beginning of the assessment.
Understanding why POTS has developed, identifying contributing mechanisms and recognising associated conditions allows treatment to be tailored to the individual. This broader assessment helps explain why two people with the same diagnosis may benefit from different management strategies.
HOW IS IT USUALLY MANAGED?
Management depends on the diagnosis, symptom severity, underlying mechanisms and each person's individual circumstances.
Current management aims to reduce symptoms, improve daily functioning and increase quality of life. Treatment usually combines education, lifestyle measures, rehabilitation and, where appropriate, medication. The most appropriate approach depends on each person's symptoms, underlying mechanisms and associated conditions.
The foundations of management generally include:
increasing fluid intake
increasing dietary salt where medically appropriate
wearing compression garments to reduce blood pooling
avoiding prolonged standing where possible
learning physical counter-pressure manoeuvres that can reduce symptoms during standing.
A structured rehabilitation programme is recommended for many people. These programmes usually begin with recumbent or seated exercise before gradually progressing towards upright activities over several months. However, if post-exertional malaise is present, rehabilitation should be adapted accordingly rather than following a standard graded programme.
When symptoms remain significant despite these measures, medications such as beta-blockers, ivabradine, midodrine, fludrocortisone or pyridostigmine may be considered by the treating clinician. These medications are selected according to the individual's presentation, and response varies between patients.
LIVING WELL WITH THE CONDITION
Impact on Daily Life
Living with POTS can be challenging, particularly because symptoms often fluctuate from one day to the next. Many people find that activities they previously performed without difficulty—standing in a queue, taking a hot shower, climbing stairs or carrying shopping—can become unexpectedly exhausting.
Symptoms are rarely constant. Some days may feel relatively normal, while others require significant adjustments. Learning to recognise your own triggers and understanding how your body responds can help you manage the condition more effectively.
Understanding your triggers
Although triggers vary between individuals, many people notice worsening symptoms with:
prolonged standing
hot weather or hot baths and showers
dehydration
missing meals
large carbohydrate-rich meals
alcohol
menstruation
acute illness
lack of sleep
emotional or physical stress.
Keeping a simple symptom diary can help identify personal patterns. Recording symptoms alongside factors such as hydration, meals, activity, sleep and menstrual cycle can provide valuable information for both you and your healthcare professional.
Small changes can make a difference
Many people benefit from introducing practical adaptations into their daily routine, including:
rising slowly from lying or sitting
maintaining adequate hydration throughout the day
following medical advice regarding dietary salt intake
wearing compression garments when appropriate
avoiding standing still for prolonged periods
sitting whenever possible for tasks such as cooking or ironing
planning demanding activities for times of day when symptoms are less severe.
These measures may not eliminate symptoms completely, but they often reduce their impact and improve confidence in everyday activities.
Exercise and rehabilitation
Many people with POTS become understandably concerned about exercise because activity can temporarily worsen symptoms. However, avoiding activity altogether may contribute to further deconditioning, making symptoms progressively more difficult to manage.
Current evidence supports carefully structured rehabilitation programmes that begin with recumbent or seated exercise, such as recumbent cycling, rowing or swimming, before gradually progressing to upright activities over several months.
It is important to recognise that some people feel temporarily worse during the first few weeks of rehabilitation before improvements become noticeable. Understanding this in advance can help maintain motivation during the early stages of recovery.
However, people who experience post-exertional malaise (PEM) require a different approach. If physical or mental activity consistently leads to a delayed worsening of symptoms one or two days later, rehabilitation should be adapted accordingly rather than following a standard graded exercise programme.
Looking after your wellbeing
Living with a long-term condition can affect emotional wellbeing as well as physical health. Many people describe frustration, uncertainty and reduced confidence, particularly during the period before receiving a diagnosis.
These reactions are understandable. Receiving appropriate assessment, education and support often helps people regain confidence and develop strategies to manage symptoms more effectively while maintaining as much independence and quality of life as possible.
HOW ROWAN HEALTH SUPPORTS YOU
At Rowan Health, our approach begins with understanding why your symptoms are occurring, rather than focusing solely on the diagnosis.
During your assessment, we explore not only whether you meet the diagnostic criteria for POTS, but also the biological and clinical factors that may be contributing to your symptoms. These may include reduced blood volume, altered autonomic regulation, physical deconditioning or associated conditions such as Long COVID, ME/CFS, joint hypermobility or migraine.
Following your assessment, we develop an individualised supportive care plan designed to complement your conventional medical care.
Depending on your individual needs, this may include:
education about autonomic dysfunction and symptom management
support with hydration, lifestyle and rehabilitation strategies
guidance on pacing and activity management
monitoring of symptom progression and functional improvement
management of associated symptoms affecting sleep, fatigue, pain or wellbeing
personalised integrative supportive care delivered alongside NHS or specialist treatment.
Our aim is to help you better understand your condition, improve day-to-day functioning and support long-term self-management through an evidence-informed, person-centred approach.
When to Seek Medical Advice
Symptoms such as dizziness, palpitations and fatigue are common in POTS, but they can also occur in other medical conditions. It is important not to assume that every episode is caused by POTS.
You should seek prompt medical assessment if you experience:
chest pain
loss of consciousness, particularly without warning
fainting during exercise
new neurological symptoms such as weakness or difficulty speaking
persistent or unexplained weight loss
severe or worsening breathlessness
new or rapidly worsening symptoms without an obvious explanation.
Call 999 immediately if you experience severe chest pain, symptoms of stroke, prolonged loss of consciousness or any other medical emergency.
If your symptoms are severe, rapidly worsening or causing immediate concern, contact NHS 24 on 111. In a medical emergency, call 999 or attend your nearest Accident & Emergency department.
FAQs
Is POTS a heart disease?
No. POTS is a disorder of the autonomic nervous system that affects how heart rate and blood circulation are regulated when standing. Although symptoms involve the cardiovascular system, the heart itself is usually structurally normal.
Can POTS improve?
Yes. Many people experience meaningful improvement over time, particularly with appropriate education, lifestyle measures, rehabilitation and supportive care protocols. The degree of improvement varies between individuals.
Is POTS the same as anxiety?
No. POTS is diagnosed using objective physiological measurements during standing tests. While anxiety and POTS can occur together, the excessive increase in heart rate seen in POTS reflects changes in autonomic regulation rather than anxiety alone.
Can COVID-19 cause POTS?
Yes. POTS has been recognised as one possible consequence of COVID-19 infection in some people. However, POTS may also develop after other viral illnesses or without any identifiable trigger.
Can I still exercise if I have POTS?
In many cases, yes. Structured rehabilitation is considered an important part of management, but programmes should be tailored to the individual. If post-exertional malaise is present, the approach should be modified accordingly.
Sources & references
The information presented on this page is based on current international clinical guidelines and peer-reviewed scientific literature. Our aim is to provide accurate, evidence-informed information to help patients better understand Postural Orthostatic Tachycardia Syndrome (POTS). This information is intended for educational purposes and should not replace individual medical advice from your healthcare professional.
Clinical Guidelines and Position Statements
Sheldon RS, Grubb BP II, Olshansky B, et al. (2015). 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope. Heart Rhythm, 12(6), e41–e63.
Raj SR, Guzman JC, Harvey P, Richer L, Schondorf R, Seifer C, Thibodeau-Jarry N, Sheldon RS. (2020). Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance. Canadian Journal of Cardiology, 36(3), 357–372. https://doi.org/10.1016/j.cjca.2019.12.024
Review Articles
Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. (2019). Postural Orthostatic Tachycardia Syndrome. Journal of the American College of Cardiology, 73(10), 1207–1228.
Fedorowski A. (2019). Postural Orthostatic Tachycardia Syndrome: Clinical Presentation, Aetiology and Management. Journal of Internal Medicine, 285(4), 352–366.
Raj SR, Fedorowski A, Sheldon RS. (2022). Diagnosis and Management of Postural Orthostatic Tachycardia Syndrome. Canadian Medical Association Journal (CMAJ), 194(10), E378–E385. https://doi.org/10.1503/cmaj.211373
Expert Consensus Reviews
Vernino S, Bourne KM, Stiles LE, 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, 235, 102828. https://doi.org/10.1016/j.autneu.2021.102828
Raj SR, Bourne KM, Stiles LE, et al. (2021). Postural Orthostatic Tachycardia Syndrome (POTS): Priorities for POTS Care and Research from a 2019 National Institutes of Health Expert Consensus Meeting – Part 2. Autonomic Neuroscience, 235, 102836. https://doi.org/10.1016/j.autneu.2021.102836
Exercise and Non-Pharmacological Management
Fu Q, Levine BD. (2018). Exercise and Non-pharmacological Treatment of Postural Orthostatic Tachycardia Syndrome. Autonomic Neuroscience, 215, 20–27.
Clinical Review
Clinical content reviewed by
Rowan Health
Last reviewed:
27 July 2026
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Would You Like Personalised Support?
Living with POTS can be challenging, particularly when symptoms fluctuate or overlap with other long-term conditions. At Rowan Health, we provide comprehensive assessments to better understand the factors contributing to your symptoms and develop an individualised supportive care plan tailored to your needs.
Our evidence-informed approach works alongside your existing medical care, helping you understand your condition, improve daily functioning and build practical strategies for long-term self-management.
Book an Initial Assessment or arrange a free 10-minute Discovery Call to discuss whether our personalised supportive care approach may be appropriate for you.