Postural Orthostatic Tachycardia Syndrome (POTS) is a complex, chronic condition that falls under the umbrella of dysautonomia, a disorder of the autonomic nervous system. This system controls involuntary body functions like heart rate, blood pressure, and digestion. In people with POTS, the body struggles to coordinate blood vessel constriction and heart rate response when transitioning to an upright position, leading to debilitating symptoms like lightheadedness, fatigue, and a rapid heart rate. Obtaining a diagnosis can be challenging, as symptoms often overlap with other conditions, resulting in an average delay of several years before the correct specialist is found.
The Initial Consultation and Referral Pathway
The journey to a POTS diagnosis typically begins with a primary care physician (PCP). The PCP performs a thorough history and physical exam to rule out common causes of symptoms, such as anemia, thyroid dysfunction, or dehydration. Common symptoms suggesting POTS include a racing heart, dizziness, and fatigue that worsen with standing and improve when lying down. A simple in-office assessment, like the Active Stand Test, can provide the first objective evidence of orthostatic intolerance. If initial screenings are inconclusive, the PCP initiates a referral to a specialist who can perform definitive diagnostic procedures. Referral is warranted when an adult experiences a sustained heart rate increase of 30 beats per minute or more within ten minutes of standing, without a significant drop in blood pressure.
Primary Specialists Responsible for Diagnosis
The specialists who ultimately confirm a POTS diagnosis usually come from one of two medical disciplines, reflecting the condition’s dual nature involving both the circulatory and nervous systems. Cardiologists, particularly those who specialize in cardiac electrophysiology, are frequently involved because the defining feature of POTS is the excessive increase in heart rate, or tachycardia, when standing upright. Electrophysiologists focus on the electrical activity and rhythm of the heart, making them well-suited to evaluate the cardiac component. Neurologists, especially those sub-specializing in autonomic disorders, are the other main group of physicians responsible for the diagnosis. Since POTS is fundamentally a form of dysautonomia, a neurologist with expertise in this area can best assess the underlying nerve dysfunction. The choice between a cardiologist and a neurologist often depends on the physician’s specific experience with autonomic dysfunction and the availability of specialized testing centers.
Key Diagnostic Procedures Used
The definitive confirmation of POTS relies on specific physiological tests that measure the body’s response to gravity. The gold standard for diagnosis is the Tilt Table Test, a procedure in which the patient is strapped to a motorized table that is slowly tilted to an upright position. Heart rate and blood pressure are continuously monitored during this test to document the characteristic heart rate surge; a sustained increase of at least 30 beats per minute in heart rate for adults confirms the diagnosis. The Active Stand Test is a simpler screening tool involving measurements taken after lying down, and then again at one, three, five, and ten minutes of quiet standing. Beyond these orthostatic tests, other procedures may be used to identify the underlying subtype of POTS or rule out other conditions, such as Quantitative Sudomotor Axon Reflex Testing (QSART), which measures sweat output to check for small fiber neuropathy.
Coordinating Long-Term Care
Once the diagnosis of POTS is confirmed, the focus shifts to comprehensive, long-term management, which typically requires a multidisciplinary team approach. Because POTS can affect multiple body systems, care is often coordinated by a physician familiar with autonomic disorders, such as an internist, cardiologist, or neurologist, who works alongside various other specialists. Physical therapists play a significant role by developing a gradual, structured exercise program, often starting with supine exercises, to improve exercise tolerance and combat the deconditioning that frequently occurs. Dietitians can provide guidance on nutritional modifications, such as increasing fluid and salt intake to help expand blood volume, which is often low in people with POTS. Mental health professionals, including psychologists, help patients manage the secondary effects of living with a chronic illness, such as anxiety, depression, and the cognitive challenges known as “brain fog.” This coordinated care structure ensures that the wide-ranging and fluctuating symptoms of POTS are addressed holistically, moving beyond the initial diagnosis to a strategy for improving daily function.