History and exam
Key diagnostic factors
common
orthostatic tachycardia
Check the patient’s heart rate and blood pressure while they are supine and then standing.[2] This is known as the 10-minute standing test.
The patient’s heart rate will typically increase by ≥30 bpm (or ≥40 bpm in patients ages 12 to 19 years old) after changing position from supine to standing, with no orthostatic hypotension (sustained drop in systolic blood pressure by ≥20 mmHg).[1][2][3][4]
Allow at least 5 minutes of a supine position and at least 1 minute of standing before checking orthostatic vital signs.[40] If there is no significant variation in the patient’s heart rate after 1 minute of standing, repeat the standing heart rate and blood pressure check at 3, 5, and 10 minutes.[40]
Note that changes in heart rate are often not apparent after 1 minute of standing in practice. A common mistake is to focus on the changes in heart rate after 1 minute of standing only, rather than the full 10 minutes, which can lead to misdiagnosis.
Be aware that some patients have hyperadrenergic POTS, and have increased sympathetic response and excess circulating catecholamine.[1][2] Patients with hyperadrenergic POTS will have orthostatic hypertension (increase in systolic blood pressure ≥10 mmHg after standing for 10 minutes).[2]
orthostatic palpitations
A key orthostatic symptom of POTS.[1][2][3][4] Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] A patient with POTS may report palpitations even if they have a normal heart rate, particularly if they are taking negative chronotropic medications (e.g., beta-blockers, ivabradine). For a diagnosis of POTS, orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1]
presence of risk factors
Consider POTS if a patient presents with relevant symptoms and signs and particularly if they have any of the following risk factors:
Other diagnostic factors
common
orthostatic lightheadedness
An orthostatic symptom of POTS.[1][3][4] It occurs due to rapid heart rate and hypoperfusion on standing. Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
orthostatic blurred vision
An orthostatic symptom of POTS.[1] Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
exercise intolerance
Can be an orthostatic or non-orthostatic feature of POTS.[1][2][4] Postexercise malaise is a frequently reported symptom. Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
orthostatic presyncope
Presyncope is an orthostatic symptom of POTS.[2] It occurs due to rapid heart rate and hypoperfusion while standing. Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
orthostatic tremor
Tremor is an orthostatic symptom of POTS.[1][2][4] Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
orthostatic generalized weakness
Generalized weakness is an orthostatic symptom of POTS.[1][2] Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
uncommon
orthostatic syncope
Syncope is an orthostatic symptom of POTS.[2] It may occur due to excessive tachycardia and transient hypoperfusion while standing. Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, the patient should also have an increase in heart rate by ≥30 bpm within 10 minutes of standing from a supine position or head-up tilt, without orthostatic hypotension, and orthostatic symptoms should occur frequently and have lasted for at least 3 months.[1][2][4]
bloating
A gastrointestinal feature of POTS.[2][3][4] Gastrointestinal symptoms are occasionally reported by people with POTS and may be due to autonomic dysfunction, or associated irritable bowel disease or celiac disease.[34] For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
nausea
A gastrointestinal feature of POTS, which can be accompanied by fainting and migraines.[2][3][4] Gastrointestinal symptoms are occasionally reported by people with POTS and may be due to autonomic dysfunction, or associated irritable bowel disease or celiac disease. For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
diarrhea
A gastrointestinal feature of POTS.[2][3][4] Gastrointestinal symptoms are occasionally reported by people with POTS and may be due to autonomic dysfunction, or associated irritable bowel disease or celiac disease. For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
constipation
A gastrointestinal feature of POTS.[4][34] Gastrointestinal symptoms are occasionally reported by people with POTS and may be due to autonomic dysfunction, or associated irritable bowel disease or celiac disease. For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
abdominal pain
A gastrointestinal feature of POTS.[2][3][4] Gastrointestinal symptoms are occasionally reported by people with POTS and may be due to autonomic dysfunction, or associated irritable bowel disease or celiac disease. For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
fatigue
Can be an orthostatic or non-orthostatic feature of POTS.[1][2][3][4] The patient may describe muscle fatigue and low energy. Orthostatic symptoms of POTS occur when standing and improve rapidly when the patient returns to a supine position.[1][2] For a diagnosis of POTS, symptoms should have lasted for at least 3 months.[1]
headache
sleep disturbance
cognitive impairment
chest pain
Risk factors
strong
young age (15 to 25 years)
Most patients who present with POTS are typically young women ages 15 to 25 years.[2][10] However, POTS can occur outside of this age range, although new onset POTS is rare after age 50.[2] Patients <12 years may present with similar symptoms to older patients, particularly if there is a family history of POTS.[1] However, POTS remains undefined in patients <12 years and the sensitivity and specificity of the heart rate criteria in this age group is not established.[1]
recent viral infection
pregnancy
Hormonal changes during pregnancy affect peripheral vascular resistance and blood volume, which may trigger orthostatic intolerance, particularly early in pregnancy (i.e., the first trimester).[18]
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