When should I refer a patient with suspected POTS to a specialist for further evaluation and management?

Refer a patient with suspected postural orthostatic tachycardia syndrome (POTS) to a specialist for further evaluation and management if:

• Symptoms of orthostatic intolerance are present but blood pressure measurements do not confirm postural hypotension, indicating the need for specialist cardiovascular assessment.
• The patient experiences significant orthostatic symptoms such as light-headedness, palpitations, or near-fainting on standing that impair daily functioning.
• There is diagnostic uncertainty after initial assessment in primary care, or if symptoms are severe enough to limit the patient’s ability to sit or stand for any length of time.

Specialist referral is important to confirm diagnosis, exclude other causes of syncope or orthostatic intolerance, and to guide management tailored to the patient’s condition.

This approach aligns with NICE guidance on orthostatic intolerance and syncope, which recommends specialist cardiovascular assessment when postural hypotension is not confirmed but symptoms persist, and when complex or severe presentations occur NICE NG206,NICE CG109.