What clinical criteria should I use to diagnose Postural Orthostatic Tachycardia Syndrome (POTS) in my patients?

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) ¹; 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 ¹.
• Symptoms should be chronic, typically lasting at least 3 to 6 months to distinguish POTS from transient orthostatic tachycardia (Raj et al., 2020; Olshansky 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) ¹.
• Other causes of tachycardia and orthostatic intolerance should be excluded, including dehydration, anemia, medication effects, cardiac arrhythmias, and other autonomic disorders ¹.

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 ¹. The presence of autonomic dysfunction symptoms such as temperature sensitivity, neuromuscular symptoms, and post-exertional malaise may coexist but are not diagnostic criteria ¹.

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 ¹; 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., 2020; Olshansky et al., 2020).