Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)
POTS presents with three distinct symptom categories: orthostatic symptoms triggered by standing, autonomic symptoms, and systemic symptoms that persist regardless of posture. 1
Orthostatic Symptoms (Triggered by Standing)
These symptoms develop upon standing and are relieved by sitting or lying down:
- Lightheadedness and dizziness are the most prominent complaints in POTS patients 1
- Palpitations from the excessive heart rate increase 2, 1
- Tremulousness and generalized weakness that worsen with upright posture 2
- Blurred vision and other visual disturbances including tunnel vision or enhanced brightness 2, 1
- Exercise intolerance that prevents return to normal activity levels 2, 3
- Pre-syncope (feeling like you're about to faint), though actual syncope is less common than in orthostatic hypotension 1
Autonomic Activation Symptoms
These reflect sympathetic nervous system overactivity:
- Pallor and sweating from sympathetic overactivity 1
- Nausea as a common manifestation 1, 3
- Chest discomfort or pain 1
- Tachycardia with standing heart rate often exceeding 120 bpm 2
Gastrointestinal Symptoms (Not Posture-Related)
- Bloating, nausea, diarrhea, and abdominal pain that occur independent of posture 2, 3
- Abdominal discomfort is frequently reported 3
Systemic Symptoms
These persist regardless of position:
- Extreme fatigue is a hallmark feature 2, 1, 4
- Sleep disturbances 2, 1
- Migraine headaches 2, 3
- Mental clouding and cognitive complaints (often described as "brain fog") 1, 4
- Postexertional malaise 1
Temporal Patterns and Exacerbating Factors
Symptoms characteristically worsen under specific conditions: 1
- Morning hours after waking (symptoms often most severe) 1
- After meals (postprandial exacerbation) 1
- Heat exposure 1
- After physical exertion 1
Key Diagnostic Features
The diagnosis requires all three criteria:
- Heart rate increase ≥30 bpm within 10 minutes of standing (≥40 bpm in ages 12-19) 2, 1
- Frequent symptoms occurring with standing as described above 2
- Absence of orthostatic hypotension (no sustained systolic BP drop ≥20 mmHg or diastolic drop ≥10 mmHg) 2, 1
- Symptoms must persist for at least 3 months for formal diagnosis 1
Common Pitfalls
POTS must be distinguished from other causes of tachycardia: 1
- Inappropriate sinus tachycardia
- Anxiety disorders (though these can coexist)
- Dehydration
- Anemia
- Hyperthyroidism
- Pheochromocytoma
POTS frequently coexists with: 1
- Deconditioning (especially after illness or injury) 3
- Recent viral infections 5
- Chronic fatigue syndrome
- Joint hypermobility syndrome and hypermobile Ehlers-Danlos syndrome
- Functional gastrointestinal disorders 6
Demographics
POTS predominantly affects young women of childbearing age, with symptoms often first appearing in adolescence within 1-3 years of their growth spurt 1, 3