What are the signs and symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)?

Signs and Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)

POTS presents with orthostatic intolerance symptoms—most commonly lightheadedness, palpitations, tremor, weakness, blurred vision, and fatigue—triggered by standing, accompanied by an excessive heart rate increase (≥30 bpm within 10 minutes of standing, or ≥40 bpm in ages 12-19) without orthostatic hypotension, predominantly affecting young women. 1, 2

Cardinal Diagnostic Features

The diagnosis requires both physiologic criteria and symptom presentation:

• Heart rate increase ≥30 bpm within 10 minutes of standing (≥40 bpm for patients aged 12-19 years), often reaching ≥120 bpm 1, 2, 3
• Absence of orthostatic hypotension (no sustained systolic BP drop ≥20 mmHg or diastolic BP drop ≥10 mmHg) 1, 2, 4
• Symptoms must persist for at least 3 months for formal diagnosis 2

Primary Orthostatic Symptoms

These symptoms develop upon standing and are relieved by sitting or lying down:

• Lightheadedness and dizziness are the most prominent complaints, reported by 97.6% of patients 1, 2, 5
• Palpitations from the excessive tachycardia 1, 2
• Tremulousness and generalized weakness 1, 2
• Blurred vision and other visual disturbances including tunnel vision 1, 2
• Presyncope (feeling faint), though actual syncope is rare and usually occurs only when vasovagal reflex is activated 1, 6

Autonomic Activation Signs

Sympathetic overactivity manifests as:

• Pallor and sweating 2
• Nausea 1, 6
• Chest discomfort or pain 1, 2, 7

Non-Specific Associated Symptoms

POTS frequently includes symptoms beyond orthostatic intolerance:

• Profound fatigue that is not alleviated by rest 1, 2
• Exercise intolerance with inability to return to normal activity levels 1, 6
• Cognitive complaints including memory impairment, attention deficit, and "brain fog" 1, 2
• Headache 2, 6
• Sleep disturbances or nonrestorative sleep 1, 2
• Postexertional malaise (worsening after physical activity) 1, 2
• Shortness of breath 1, 7
• Abdominal discomfort and gastrointestinal symptoms 3, 6

Temporal Pattern and Exacerbating Factors

Symptoms follow a predictable pattern:

• Develop upon standing and relieved by sitting or lying down 2
• Worse in morning hours after waking 2
• Exacerbated by heat exposure 2
• Worsened after meals (postprandial) 2
• Precipitated by exertion 2
• Symptoms typically occur within <10 minutes of standing 1

Functional Impairment

Patients report substantial disability:

• Average of 3.0 days completely lost per week from normal activities 5
• Average of 4.7 unproductive days per week 5
• Inability to maintain work, school, or home activities 1, 6

Demographics and Associated Conditions

• Predominantly affects young women (approximately 90% female) 1, 2, 5
• Often follows recent infection or trauma 1, 2
• Frequently associated with joint hypermobility syndrome or Ehlers-Danlos syndrome 1, 2
• May follow period of deconditioning from illness or injury 2, 6
• 42% of cases preceded by viral infection in pre-COVID studies 1

Critical Diagnostic Pitfalls

POTS must be distinguished from other conditions causing tachycardia:

• Inappropriate sinus tachycardia (tachycardia present even when supine) 2, 3
• Anxiety disorders (though anxiety may coexist with POTS) 2, 3
• Dehydration (correctable with acute fluid administration) 2
• Anemia (check hemoglobin) 2
• Hyperthyroidism (check thyroid function) 2
• Pheochromocytoma (check catecholamines if hyperadrenergic features prominent) 2

Note that POTS phenotypes (neuropathic, hyperadrenergic, hypovolemic) cannot be distinguished by symptoms alone—specific testing is required if phenotyping is desired. 5