GPAtlas🧭 When to suspect
Postural Tachycardia Syndrome (PoTS) is a chronic disorder of autonomic (orthostatic) regulation. Its cardinal feature is an excessive rise in heart rate on standing without a fall in blood pressure, accompanied by symptoms of orthostatic intolerance – light-headedness, palpitations, fatigue and “brain fog” – that are provoked by standing and relieved by sitting or lying down.
It predominantly affects women (roughly 80%), with onset most often in adolescence or young adulthood. There is a strong association with a preceding viral illness – long COVID and glandular fever are common triggers – and with joint hypermobility / hypermobile Ehlers–Danlos syndrome (hEDS) and myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS). Symptoms are genuinely disabling and are frequently mislabelled as anxiety.
The diagnosis is clinical, confirmed with an active stand test, after excluding mimics. The thresholds below are the core of recognition.
| Diagnostic feature | Threshold / requirement |
|---|---|
| Heart rate rise on standing (adults ≥ 19 years) | Sustained increase of ≥ 30 beats per minute (bpm) within 10 minutes |
| Heart rate rise (adolescents 12–19 years) | Sustained increase of ≥ 40 bpm within 10 minutes |
| Blood pressure | No orthostatic hypotension – no sustained fall ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic |
| Symptom duration | ≥ 3 months of orthostatic intolerance |
| Symptom pattern | Provoked by standing, relieved by sitting or lying down |
| Exclusion | No acute cause (dehydration, acute illness, drugs) and no other condition that fully explains the tachycardia |
|
🧠 Clinical pearl PoTS is repeatedly mislabelled as anxiety or panic. The tachycardia, tremor and breathlessness are real autonomic phenomena, not somatisation – and the patient may have been disbelieved for years. Before attributing orthostatic symptoms to anxiety, measure the heart-rate response to standing; an objective rise reframes the whole consultation. |
Source: Heart Rhythm Society 2015 consensus · BMJ 2023
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