Clinical criteria to diagnose Postural Orthostatic Tachycardia Syndrome (POTS) include:
- A sustained increase in heart rate of ≥30 beats per minute (bpm) within 10 minutes of standing or head-up tilt, without orthostatic hypotension (a significant drop in blood pressure) NICE NG206; this criterion is generally accepted in clinical practice and supported by expert consensus Raj et al. 2020.
- In patients aged 12–19 years, a heart rate increase of ≥40 bpm may be used to account for physiological differences Raj et al. 2020.
- Symptoms of orthostatic intolerance must be present, such as light-headedness, palpitations, tremulousness, chest pain, headaches, blurred vision, nausea, or near-fainting that worsen on standing and improve on sitting or lying down NICE NG206.
- Symptoms should be chronic, typically lasting at least 3 to 6 months to distinguish POTS from transient orthostatic tachycardia Raj et al. 2020Olshansky et al. 2020.
- There should be no significant orthostatic hypotension (a drop in systolic blood pressure ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing) NICE NG206.
- Other causes of tachycardia and orthostatic intolerance should be excluded, including dehydration, anemia, medication effects, cardiac arrhythmias, and other autonomic disorders NICE NG206.
Additional clinical considerations: The diagnosis is clinical and supported by careful history taking and physical examination focusing on orthostatic symptoms and heart rate response to standing. Tilt-table testing can be used in specialist settings but is not routinely required in primary care NICE NG206. The presence of autonomic dysfunction symptoms such as temperature sensitivity, neuromuscular symptoms, and post-exertional malaise may coexist but are not diagnostic criteria NICE NG206.
In summary, the key diagnostic criteria for POTS are a sustained orthostatic tachycardia without hypotension, accompanied by orthostatic intolerance symptoms lasting for several months, after excluding other causes NICE NG206; this is consistent with the Canadian Cardiovascular Society position and recent literature emphasizing the importance of symptom chronicity and exclusion of other diagnoses Raj et al. 2020Olshansky et al. 2020.
Key References
- NG206 - Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management
- CG109 - Transient loss of consciousness ('blackouts') in over 16s
- (Kim et al., 2019): Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria.
- (Raj et al., 2020): Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance.
- (Olshansky et al., 2020): Postural Orthostatic Tachycardia Syndrome (POTS): A critical assessment.