Positional Orthostatic Tachycardia Syndrome -an overview

As it is becoming increasingly obvious that a large proportion of Long Covid symptoms are a result of a dysautonomia most commonly Positional Orthostatic Tachycardia Syndrome (POTS) I thought I would just do a quick recap on it's main features again for any new followers!

This blog is based on a recent Webinar with Dr Satish Raj a research doctor at the University of Calgary and also a member of the Dysautonomia International Medical Advisory Board

POTS has a definition of an increased heart rate of greater than 30 bpm on standing - orthostatic tachycardia. (> 40 bpm if under 18 years of age).

The diagnosis is proved with a tilt table test but doctors can diagnose it by taking heart rate and blood pressure recordings for 10 minutes upon standing from a lying down position.

These heart rate changes are only the physiological changes.

POTS is a syndrome with symptoms characteristically worsening when upright and that resolve when lying down. It needs to persist for more than 6 months although doctors some will diagnose at 3 months.


Pre-pandemic POTS was most commonly diagnosed in girls and women and predominately Caucasians. The most common age of onset was 14 years of age with significant missed school and delayed entry into tertiary education. As a syndrome there is no ONE reason as to why we may develop POTS. Dr David Robertson described it as a result of “ a final common pathway of genetics, acquired autonomic and cardiovascular entities”. It is a multi system disorder with a wide range of symptoms:

  • Rapid heart beat - tachycardia, palpitations

  • Chest pain

  • Shortness of breath

  • Lightheaded/dizziness

  • Presyncope - near fainting

  • Brain fog - cognitive blunting

  • Headache

  • Migraine

  • Nausea, vomiting

  • Tremor

  • Memory issues

  • Muscle aches

  • Coathanger pain - shoulder and upper chest pains

  • Raynaud’s syndrome - cold hands and feet

  • Abdominal pain

  • Exercise intolerance

  • Fatigue

  • Insomnia

  • Unrefreshing sleep

  • Anxiety NB - as a symptom

Mental health:

Many are diagnosed with a psychiatric issue at first and formal diagnosis can take on average 8 years due to this. However there is NO increase in prevalence in depression, anxiety or panic attacks in patients with POTS. However there is an increase in ADHD traits.

Quality of Life:

A person with POTS has a poor Quality of Life (QoL) comparable to those with severe, chronic back pain and those requiring daily dialysis. Of those with a poor QoL is is estimated that 60% is down to poor quality/ unrefreshing sleep.

Current theories of the cause of POTS:

  • Mast Cell Activation Syndrome

  • Autonomic neuropathy

  • Hypovolaemia

  • Hyperadrenergic

  • Autoantibodies

  • Hypermobility/ Ehler Danlos Syndrome


  • Full history and examination

  • Heart rate and blood pressure on standing

  • Blood tests

  • Tilt table test

  • Echocardiogram (ECHO) to exclude heart defect

  • Estimation of circulating blood volume

  • Exercise capacity - Cardio Pulmonary Exercise Test CPET


  • 2-3 litres of water a day

  • Increase salt in diet

  • Exercise training to improve fitness levels, increase blood volume, switch to parasympathetic state, reduce orthostatic intolerance and increase QoL

  • Suggested regimen based on CHOP modified protocol - 4 times a week aerobic activity increasing from 30 minutes to an hour over time ( recumbent cycling, rowing, swimming), lower limb resistance training with resistance bands. This will take at least 4-6 weeks to see any improvement and you may feel worse initially. **If you are post Covid please determine if you have post exertion malaise first in order to avoid a relapse**

  • Heart rate controlling medication - propranolol and ivabradine

  • Advice on how to “live with a chronic illness”

  • For a severe relapse attend A&E/ ED for intravenous saline

Suggested further reading from RoseCottageDoc!

  • Follow Dysautonomia International on Facebook

  • Look up POTS UK website

  • I have some info on how to diagnose POTS, exercise links on my on my Instagram page @rosecottagedoc

  • Follow @potsieprobs @spoonie_village @colurblind_zebra

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