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POTS (Postural Orthostatic Tachycardia Syndrome)

POTS is a health problem caused by blood flowing incorrectly in the body. Symptoms, including fast heart rate, dizziness, and even fainting, usually happen when people stand or sit up. These symptoms can make it hard to do everyday things.

  • For Patients
  • For Physicians
For Patients

POTS is a health problem caused by blood flowing incorrectly in the body. Symptoms, including fast heart rate, dizziness, and even fainting, usually happen when people stand or sit up. These symptoms can make it hard to do everyday things.

What Happens in POTS?

People with POTS can feel dizzy, lightheaded, short of breath, and super tired. Their heart may beat really fast, and they might feel confused or have trouble thinking clearly (this is called “brain fog”).

It is most common in young women and sometimes people wrongly assume the symptoms are caused by stress or anxiety.1

POTS often happens along with other health problems like:2

Why Does POTS Happen?

When people with POTS stand up, more blood stays in their legs and stomach area instead of going to the upper body and brain.3

This means that their heart does not fill up with enough blood to pump out to the rest of the body.4 This causes less blood to get to the brain when they are standing, which makes them feel faint or dizzy.5

Orthostatic intolerance
This diagram shows what happens in the body to cause symptoms of POTS/OI.10 CC BY

A Possible New Treatment

Some people with POTS have a compressed vein in their lower body. Doctors have found that putting a small tube (called a stent) in the vein can help keep the vein open and fix blood flow. This might be a potential new treatment for some POTS patients.

Common Symptoms

  • Fast heartbeat
  • Feeling your heart race or skip
  • Chest pain or tightness
  • Feeling faint or dizzy
  • Blurry vision or “tunnel vision”
  • Feeling tired all the time
  • Trouble thinking clearly
  • Weak muscles
  • Difficulty exercising or being active
POTS legs
Because of changes in blood flow, patients with POTS/OI often have a dramatic difference in color of their legs while standing (right) compared to people without POTS/OI (left).11 CC BY

How Many People Have It?

It is estimated that about 3 million people in the U.S. have POTS.6 Many people with POTS feel as sick as people with serious heart or lung problems.7

Around 1 in 4 people with POTS can’t work because they feel too sick.8

Treatment Options

  • Special exercise programs that start easy and build up in intensity
  • Getting fluids through an IV
  • Drinking more water and eating more salt
  • Wearing compression stockings to help with blood flow
  • Taking medicine to help the heart or to help blood move better
  • Breathing exercises
  • Vagus nerve therapy (a special treatment to calm the nervous system)

SAFIRE and Research

We need more doctors who understand POTS and better treatments that are backed by science. SAFIRE is helping to raise money for research to find new ways to treat POTS.

Dr. Spencer and Dr. Cutchins are studying how a stent in the iliac vein may help people with POTS who also have a compressed vein.9

SAFIRE can also help people find the right doctors and care teams for their unique needs.

References

  1. Zadourian A, Doherty TA, Swiatkiewicz I, Taub PR. Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management. Drugs. 2018;78(10):983–994.
  2. Elhage Hassan M, Steinberg RS, Abojaib L, et al. Association of Postural Orthostatic Tachycardia Syndrome and Orthostatic Intolerance with Pelvic Venous Disorders: a retrospective cross-sectional study. 2025. https://ssrn.com/abstract=5235087.
  3. Stewart JM, Medow MS, Cherniack NS, Natelson BH. Postural hypocapnic hyperventilation is associated with enhanced peripheral vasoconstriction in postural tachycardia syndrome with normal supine blood flow. Am J Physiol Heart Circ Physiol. 2006;291(2):H904–913.
  4. Novak P, Systrom DM, Witte A, Marciano SP. Orthostatic intolerance with tachycardia (postural tachycardia syndrome) and without (hypocapnic cerebral hypoperfusion) represent a spectrum of the same disorder. Front Neurol. 2024;15:1476918.
  5. Khan MS, Miller AJ, Ejaz A, et al. Cerebral Blood Flow in Orthostatic Intolerance. Journal of the American Heart Association. 2025;14(3):e036752.
  6. Garland EM, Celedonio JE, Raj SR. Postural Tachycardia Syndrome: Beyond Orthostatic Intolerance. Curr Neurol Neurosci Rep. 2015;15(9):60.
  7. Benrud-Larson LM, Dewar MS, Sandroni P, Rummans TA, Haythornthwaite JA, Low PA. Quality of life in patients with postural tachycardia syndrome. Mayo Clin Proc. 2002;77(6):531–537.
  8. Benrud-Larson LM, Sandroni P, Haythornthwaite JA, Rummans TA, Low PA. Correlates of functional disability in patients with postural tachycardia syndrome: preliminary cross-sectional findings. Health Psychol. 2003;22(6):643–648.
  9. Spencer EB, Saikia J, Ajeya D, Phillips R, Cutchins A. Symptomatic Improvement in Orthostatic Intolerance and Postural Orthostatic Tachycardia Syndrome and Pelvic Pain after Iliac Vein Stenting. 2025. https://ssrn.com/abstract=5235054.
  10. Hebson C, Muterspaw K, Kuo A, Borasino P, Syeda K, Anderson T. How to Care for Adolescent Patients With Orthostatic Intolerance in the Primary Care Office. Journal of Primary Care & Community Health. 2024;15. doi:10.1177/21501319241299527
  11. Raj SR. The Postural Tachycardia Syndrome (POTS): pathophysiology, diagnosis & management. Indian Pacing Electrophysiol J. 2006 Apr 1;6(2):84-99. PMID: 16943900; PMCID: PMC1501099.

 

For Physicians

Background

Postural Orthostatic Tachycardia Syndrome (POTS) and related forms of orthostatic intolerance (OI) are heterogeneous, often disabling autonomic disorders characterized primarily by impaired venous return and abnormal cardiovascular responses to orthostatic stress. These conditions are marked by dysregulated blood flow, which contributes to a wide spectrum of both acute and chronic symptoms.

Clinical Presentation

Patients with POTS/OI typically present with:

  • Orthostatic tachycardia (≥30 bpm increase in heart rate within 10 minutes of standing; ≥40 bpm in adolescents) – true POTS definition
  • Orthostatic intolerance potentially with less of a HR increase and possibly with hypotension not meeting strict criterion for POTS
  • Palpitations
  • Pre-syncope and syncope
  • Dizziness, lightheadedness
  • Chest discomfort and dyspnea
  • Visual disturbances (e.g., blurred or tunnel vision)
  • Cognitive impairment (“brain fog”)
  • Profound fatigue and exercise intolerance
  • Generalized weakness

These symptoms result in significant functional impairment and decreased quality of life. Many patients are misdiagnosed with primary psychiatric disorders (e.g., anxiety or panic disorder) prior to receiving appropriate evaluation for POTS/OI.1

Acrocyanosis in POTS – One of the more striking physical features in the postural tachycardia syndrome (POTS) is the gross change in dependent skin color that can occur with standing. The panel shows the legs of 2 people who have been standing for 5 minutes, a healthy control subject (left) and a patient with POTS (right). The patient with POTS (right) has significant dark red mottling of her legs extending up to the knees while standing, while the control subject does not have a similar discoloration.10 CC BY

Pathophysiology

Several mechanisms contribute to POTS/OI, including:

  • Segmental Blood Pooling: Upon standing, there is excessive venous pooling in the splanchnic, pelvic, and lower extremity vascular beds, with concomitant hypovolemia in the thoracic compartment.2
  • Preload Failure: Insufficient venous return leads to inadequate end-diastolic filling, resulting in decreased stroke volume and compensatory tachycardia to maintain cardiac output.3
  • Cerebral Hypoperfusion: Upright posture is associated with reduced cerebral blood flow (CBF), particularly in the anterior circulation, correlating with neurocognitive symptoms and syncope.4

Emerging evidence links POTS/OI to connective tissue disorders (e.g., Ehlers-Danlos Syndrome), autoimmune and mast cell activation syndromes, viral post-infectious syndromes (e.g., long COVID), and pelvic venous disorders (PeVD).5

Orthostatic intolerance
Simplified pathophysiologic model of orthostatic intolerance.11 CC BY

Comorbid Conditions5

Patients frequently present with comorbid diagnoses such as:

  • Ehlers-Danlos Syndrome or joint hypermobility
  • Mast Cell Activation Syndrome (MCAS)
  • Endometriosis and PCOS
  • Chronic pelvic pain and Pelvic Venous Disorders
  • Irritable Bowel Syndrome (IBS) and other GI dysmotility disorders
  • Interstitial cystitis/bladder pain syndrome
  • Migraine and TMJ dysfunction
  • Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)
  • Post-acute sequelae of SARS-CoV-2 (long COVID)

Epidemiology & Impact

  • Estimated U.S. prevalence: ~3 million individuals6
  • POTS/OI predominantly affects women aged 15 to 50 but occurs in men as well
  • Up to 25% of POTS/OI patients are unable to maintain employment due to symptom severity7
  • Quality of life reported by POTS/OI patients is similar to patients with congestive heart failure or advanced COPD8

Therapeutic Interventions

Management is multimodal and includes:

  • Non-pharmacologic therapies:
    • Graduated exercise programs (recumbent-based training initially)
    • Volume expansion through oral hydration and high-sodium diet
    • Compression garments (waist-high recommended)
    • IV saline infusions in refractory or severely hypovolemic cases
  • Pharmacologic options:
    • Vasoconstrictors: Midodrine, droxidopa, octreotide
    • Volume expanders: Fludrocortisone, desmopressin, erythropoietin
    • Heart rate control: Beta-blockers (e.g., propranolol), ivabradine
    • Sympathetic modulation: Clonidine, α-methyldopa
  • Neuromodulation & Supportive therapies:
    • Vagal nerve stimulation
    • Diaphragmatic breathing techniques

Innovative Therapies: Iliac Vein Stenting

Recent studies by Drs. Spencer and Cutchins have demonstrated that in select POTS/OI patients with evidence of iliac vein compression (e.g., May-Thurner Syndrome), endovascular intervention with iliac vein stenting can result in significant clinical improvement, presumably by restoring normal venous return and mitigating segmental blood pooling.9

Call to Action: SAFIRE

SAFIRE is actively promoting research and providing education to improve care for patients with POTS and OI. Our efforts include:

  • Expanding access to multidisciplinary autonomic care teams
  • Increasing provider training in complex dysautonomia management
  • Advocating for insurance coverage of evidence-based and emerging treatments

SAFIRE also helps patients identify appropriate subspecialists for individualized care. If you are interested in supporting our mission, please consider making a contribution through our donation page.

References

  1. Zadourian A, Doherty TA, Swiatkiewicz I, Taub PR. Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management. Drugs. 2018;78(10):983–994.
  2. Stewart JM, Medow MS, Cherniack NS, Natelson BH. Postural hypocapnic hyperventilation is associated with enhanced peripheral vasoconstriction in postural tachycardia syndrome with normal supine blood flow. Am J Physiol Heart Circ Physiol. 2006;291(2):H904–913.
  3. Novak P, Systrom DM, Witte A, Marciano SP. Orthostatic intolerance with tachycardia (postural tachycardia syndrome) and without (hypocapnic cerebral hypoperfusion) represent a spectrum of the same disorder. Front Neurol. 2024;15:1476918.
  4. Khan MS, Miller AJ, Ejaz A, et al. Cerebral Blood Flow in Orthostatic Intolerance. Journal of the American Heart Association. 2025;14(3):e036752.
  5. Elhage Hassan M, Steinberg RS, Abojaib L, et al. Association of Postural Orthostatic Tachycardia Syndrome and Orthostatic Intolerance with Pelvic Venous Disorders: a retrospective cross-sectional study. 2025. https://ssrn.com/abstract=5235087.
  6. Garland EM, Celedonio JE, Raj SR. Postural Tachycardia Syndrome: Beyond Orthostatic Intolerance. Curr Neurol Neurosci Rep. 2015;15(9):60.
  7. Benrud-Larson LM, Sandroni P, Haythornthwaite JA, Rummans TA, Low PA. Correlates of functional disability in patients with postural tachycardia syndrome: preliminary cross-sectional findings. Health Psychol. 2003;22(6):643–648.
  8. Benrud-Larson LM, Dewar MS, Sandroni P, Rummans TA, Haythornthwaite JA, Low PA. Quality of life in patients with postural tachycardia syndrome. Mayo Clin Proc. 2002;77(6):531–537.
  9. Spencer EB, Saikia J, Ajeya D, Phillips R, Cutchins A. Symptomatic Improvement in Orthostatic Intolerance and Postural Orthostatic Tachycardia Syndrome and Pelvic Pain after Iliac Vein Stenting. 2025. https://ssrn.com/abstract=5235054.
  10. Raj SR. The Postural Tachycardia Syndrome (POTS): pathophysiology, diagnosis & management. Indian Pacing Electrophysiol J. 2006 Apr 1;6(2):84-99. PMID: 16943900; PMCID: PMC1501099.
  11. Hebson C, Muterspaw K, Kuo A, Borasino P, Syeda K, Anderson T. How to Care for Adolescent Patients With Orthostatic Intolerance in the Primary Care Office. Journal of Primary Care & Community Health. 2024;15. doi:10.1177/21501319241299527

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