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

Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)

POTS presents with severe orthostatic intolerance triggered by standing, characterized by lightheadedness, dizziness, generalized weakness, fatigue, and visual disturbances, along with autonomic activation signs like palpitations, sweating, nausea, and chest discomfort. 1

Primary Orthostatic Symptoms (Develop Upon Standing)

The hallmark symptoms reflect cerebral hypoperfusion and occur characteristically when moving from lying or sitting to standing:

• Lightheadedness and dizziness are the most prominent complaints, occurring as cerebral perfusion decreases with upright posture 1
• Generalized weakness and fatigue manifest as physical depletion that worsens with standing 1
• Visual disturbances including blurred vision, enhanced brightness, loss of color perception, tunnel vision, and tremor are common 1
• Pre-syncope (feeling like you're about to faint) or actual syncope (fainting) can occur, though less common than in orthostatic hypotension 1

A critical diagnostic clue: symptoms develop upon standing and are relieved by sitting or lying down 1

Autonomic Activation Signs

These symptoms reflect sympathetic nervous system overactivity attempting to compensate for blood pressure regulation failure:

• Palpitations and tachycardia are prominent, with heart rate often exceeding 120 bpm when standing 2
• Pallor and sweating occur as part of sympathetic activation 1
• Nausea is a common manifestation of autonomic dysfunction 1
• Chest discomfort or pain reflects sympathetic overactivity 1

Non-Specific Associated Symptoms

Beyond orthostatic complaints, patients frequently report:

• Headache is commonly reported 1, 3
• Exercise intolerance with inability to return to normal activity levels 1, 3
• Cognitive complaints including mental clouding and difficulty concentrating 1, 4
• Sleep disturbances 1
• Postexertional malaise with prolonged recovery after physical activity 1
• Abdominal discomfort and functional gastrointestinal symptoms 3, 2

Temporal Pattern and Exacerbating Factors

Symptoms follow predictable patterns:

• Morning hours: Symptoms are often most severe after waking 1
• After meals: Postprandial hypotension exacerbates symptoms 1
• Heat exposure: Worsens the blood pressure drop and symptoms 1
• After exertion: Physical activity precipitates or worsens symptoms 1

Demographics and Duration

• Predominantly affects young women (approximately 80-89% female) 1, 5
• Symptoms must persist for at least 3 months for formal diagnosis 1
• Most common adolescent presentation involves teenagers within 1-3 years of their growth spurt who, after illness or injury, cannot return to normal activity 3

Critical Diagnostic Features to Confirm

To distinguish POTS from other conditions:

• Heart rate increase ≥30 bpm within 10 minutes of standing (or ≥40 bpm in patients aged 12-19 years) 1
• Absence of orthostatic hypotension (no sustained systolic BP drop ≥20 mmHg or diastolic BP drop ≥10 mmHg) 1
• Standing heart rate often 120 bpm or higher 2
• High upright plasma norepinephrine levels (≥600 pg/mL) in many patients, reflecting sympathetic activation 2, 5

Common Pitfalls in Recognition

Do not dismiss these symptoms as anxiety alone without proper positional testing, as POTS requires distinguishing from:

• Inappropriate sinus tachycardia 1
• Anxiety disorders 1
• Dehydration 1
• Anemia 1
• Hyperthyroidism 1
• Pheochromocytoma 1

The key differentiating feature is the temporal relationship to posture change and relief with recumbency 1

Associated Conditions to Screen For

POTS frequently coexists with:

• Deconditioning 1
• Recent infections 1
• Chronic fatigue syndrome 1
• Joint hypermobility syndrome 1
• Hypermobile Ehlers-Danlos syndrome 1
• Fibromyalgia 2