POTS diagnosis (UK), the NHS pathway

What POTS is

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system. When a person with POTS stands up, their heart rate increases excessively — 30 beats per minute or more within 10 minutes — without a corresponding drop in blood pressure. This causes dizziness, fainting, fatigue, brain fog, palpitations, and exercise intolerance.

POTS is most common in women aged 15–50, often triggered by viral illness, pregnancy, surgery, or trauma. It frequently co-occurs with hypermobile Ehlers-Danlos syndrome (hEDS), mast cell activation syndrome (MCAS), and ME/CFS.

Diagnostic criteria

The standard diagnostic criteria for POTS are:

• Heart rate increase of 30 bpm or more (40 bpm in adolescents aged 12–19) within 10 minutes of standing or head-up tilt.
• No significant drop in blood pressure (orthostatic hypotension is a different condition).
• Symptoms present for at least 3 months.
• Symptoms worsen on standing and improve on lying down.
• Other causes excluded (thyroid disease, anaemia, medication side effects, dehydration).

NHS tests for POTS

Active stand test (bedside):

• Heart rate and blood pressure measured after 5 minutes lying flat.
• Then measured at 2, 5, and 10 minutes after standing.
• A rise of 30+ bpm supports POTS.
• Most GPs and practice nurses can perform this.

Tilt table test (cardiology department):

• You lie strapped to a table that tilts to 60–80 degrees.
• Heart rate, blood pressure, and symptoms are monitored for up to 45 minutes.
• This is the gold standard for formal diagnosis.

Other tests to rule out alternative causes:

• 24-hour ECG (Holter monitor) to rule out arrhythmia.
• Echocardiogram to assess heart structure and function.
• Blood tests: thyroid function, B12, ferritin, glucose, full blood count.

The NHS referral pathway

Typical route:

• GP appointment. Describe symptoms, especially heart rate changes on standing. Ask for an active stand test.
• Initial tests. Blood tests to rule out thyroid, anaemia, and other causes. ECG to check for arrhythmia.
• Referral to cardiology. If active stand is positive or ECG is abnormal, ask for cardiology referral.
• Tilt table test. Cardiology arranges the formal diagnostic test.
• Specialist management. If POTS is confirmed, management may be by cardiology, autonomic specialist, or a dedicated POTS clinic (available in some regions).

If your GP dismisses you

POTS is frequently dismissed as anxiety, deconditioning, or "just getting up too fast." If this happens:

• Bring evidence: wearable heart rate data, symptom diary, or a video of your heart rate spike on standing.
• Ask for the active stand test explicitly. If the GP refuses, ask for the refusal in writing.
• Cite the diagnostic criteria and the fact that POTS is a recognised condition in NHS cardiology.
• Request a second opinion or referral directly to cardiology.
• If your GP blocks the referral, use Right to Choose in England to pick a cardiologist.

NHS treatment options

First-line (lifestyle):

• Increased fluid intake (2–3 litres daily).
• Higher salt intake (unless contraindicated by heart or kidney conditions).
• Compression garments (abdominal and leg).
• Graded recumbent exercise (swimming, rowing, recumbent cycling).
• Rising slowly from lying or sitting positions.
• Small, frequent meals rather than large ones.

Medication (specialist-prescribed):

• Fludrocortisone — increases blood volume.
• Midodrine — constricts blood vessels.
• Ivabradine — lowers heart rate.
• Beta blockers — reduce heart rate and palpitations.
• DDAVP — reduces overnight fluid loss (specialist use only).

Medication is initiated by a specialist, not a GP, due to the need for monitoring.

Frequently asked questions