Does POTS Cause Hypertension?
No, POTS does not cause hypertension—in fact, the absence of orthostatic hypotension is a defining diagnostic criterion for POTS, and the condition is characterized by orthostatic intolerance with tachycardia, not elevated blood pressure. 1, 2
Understanding POTS and Blood Pressure
POTS is explicitly defined by the absence of sustained orthostatic hypotension (no systolic BP drop ≥20 mmHg or diastolic BP drop ≥10 mmHg within 3 minutes of standing). 1, 2, 3 This is one of the five essential diagnostic criteria that must be present for at least 3 months. 1
The core hemodynamic feature of POTS is:
- Excessive tachycardia (≥30 bpm increase within 10 minutes of standing, or ≥40 bpm in ages 12-19) 1, 3
- Normal blood pressure response to standing (no orthostatic hypotension) 2, 4
- Standing heart rate often exceeds 120 bpm 1, 3
Blood Pressure Patterns in POTS
While POTS does not cause hypertension, some nuanced blood pressure patterns exist:
Initial Orthostatic Hypotension (IOH) can occur: Approximately 51% of POTS patients experience IOH (defined as BP drop >40/20 mmHg immediately upon standing), but this resolves rapidly and does not represent sustained orthostatic hypotension or chronic hypertension. 5 The BP minimum is actually lower in POTS patients with IOH compared to controls. 5
Baseline blood pressure is typically normal or slightly elevated: Research shows that baseline HR and BP may be higher in POTS compared to healthy controls, but this reflects sympathetic overactivity rather than true hypertension. 5
Pathophysiology: Why POTS Doesn't Cause Hypertension
The underlying mechanisms of POTS include:
- Peripheral denervation 4, 6
- Hypovolemia (low blood volume) 4, 7
- Hyperadrenergic state with elevated upright plasma norepinephrine 4, 7
- Deconditioning 4, 6
- Beta-receptor supersensitivity 4
These mechanisms produce excessive tachycardia as a compensatory response to maintain cerebral perfusion during upright posture, not hypertension. 6, 8 The syndrome reflects impaired cardiovascular regulation with reduced heart rate variability and baroreflex dysfunction. 5
Clinical Pitfalls to Avoid
Do not confuse sympathetic overactivity symptoms with hypertension: POTS patients experience palpitations, tremulousness, and sweating due to sympathetic activation, but these symptoms do not indicate elevated blood pressure. 2, 7
Do not misinterpret transient BP elevations: Brief BP increases during sympathetic surges are not the same as sustained hypertension and should not be treated as such. 5
Avoid antihypertensive medications that could worsen POTS: Beta-blockers are used in POTS but only in small doses for heart rate control, not for hypertension. 4 Medications that lower blood pressure (like candesartan) should be used with extreme caution as they may exacerbate orthostatic symptoms. 9
Key Diagnostic Distinction
If a patient has sustained orthostatic hypotension (BP drop ≥20/10 mmHg), they cannot be diagnosed with POTS by definition. 1, 3 The diagnosis requires explicit documentation that orthostatic hypotension is absent during the 10-minute active stand test or tilt-table testing. 3