Postural tachycardia syndrome (PoTS)

Postural tachycardia syndrome (PoTS) describes symptoms relating to an exaggerated rise in heart rate when standing, often noticeable after sitting or lying down in the context of a stable blood pressure.

Symptoms can include:

Dizziness, light-headedness, blurred vision
syncope or pre-syncope
palpitations
chest pain
breathlessness
shaking and sweating
weakness and fatigue
problems with thinking, memory and concentration (brain fog)
Neuropathic pain
Bowel symptoms – nausea, diarrhoea, bloating, constipation, abdominal pain
Insomnia

These symptoms can be caused by other conditions including anaemia, hypotension, thyroid dysfunction and concomitant mental health problems including anxiety which should be excluded.

Diagnosis:

PoTS is diagnosed when there is a sustained increase in heart rate (in adults) by >30bpm on standing from a supine position without lowering of blood pressure and symptoms of PoTs for at least 3 months.

An ‘active stand test’ where BP and HR are recorded after lying supine for 5 minutes followed by measurements at 2, 5 and 10 mins after standing. A ‘tilt table test’ is not required.

PoTS diagnosis can be made in primary care. A 12 lead ECG +/- Holter can be helpful in clarifying the cardiac rhythm at the time of symptoms if there is any doubt that symptoms might reflect an arrhythmia (ie SVT). Open access Holter monitors can be arranged from primary care (see ‘EGG’ and ‘Direct Access Ambulatory ECG monitoring’ sections on Refhelp).

Who to refer, who not to refer, how to refer

Who to refer:

Patients with cardiac-sounding SYNCOPE.
Patients with abnormal clinical examination, abnormal ECGs or Arrhythmia (ie SVT) identified on Holter monitoring.
Advice can be sought through SCI Gateway for difficult to manage cases, or if diagnostic uncertainty exists, although treatment options are likely to be limited to supportive care.

Who not to refer:

In patients with PoTS, there is usually no cardiac pathology to be found if the ECG and clinical examination are otherwise normal and patients do not usually need to be referred for Cardiology assessment. There is no clear cause for PoTS.

There is no secondary care PoTS service in NHS Borders.

Primary care management

There is no specific treatment, but symptoms of PoTS can be improved by maintaining good levels of hydration, exercise, and compression stockings.

If symptoms remain troublesome despite this, low dose beta blockers (e.g. Bisoprolol 2.5mg od) and Ivabradine (2.5 to 5mg bd) can be helpful in controlling heart rate. These can be trialled in primary care and do not require referral to secondary care. There is no firm evidence-based treatments for PoTS but some international guidelines and consensus statements support these recommendations.

Use 10-minute standing protocol - Passive Standing Test Protocol.docx

Resources and links

Further information can be found at:

Last reviewed: 01/09/2025

Next review date: 01/09/2027

Author(s): Dr. Pinky Yadav .

Author email(s): Pinky.yadav@borders.scot.nhs.uk.