POTS (Postural Orthostatic Tachycardia Syndrome)¶

VERSION: 1.1 CREATED: February 8, 2026 REVISED: February 8, 2026 STATUS: Draft - Pending Review

DIAGNOSIS: Postural Orthostatic Tachycardia Syndrome (POTS)

ICD-10: G90.A (Postural orthostatic tachycardia syndrome)

CPT CODES: 85025 (CBC), 80048 (BMP), 84443 (TSH), 83540 (Iron, serum), 83550 (Iron binding capacity/TIBC), 82728 (Ferritin), 82382 (Catecholamines, fractionated), 84681 (C-peptide), 86235 (ANA), 86364 (Anti-nuclear antibody/tissue transglutaminase IgA), 83516 (Immunoassay — ganglionic AChR Ab), 95924 (Autonomic function testing, including tilt table), 95923 (QSART, quantitative sudomotor axon reflex test), 95922 (Valsalva maneuver with HR/BP monitoring), 93000 (12-lead ECG), 93306 (Transthoracic echocardiogram), 95816 (EEG), 70553 (MRI brain with/without contrast), 72156 (MRI cervical spine), 88305 (Skin biopsy pathology — IENFD), 82533 (Cortisol), 82785 (Tryptase)

SYNONYMS: POTS, postural tachycardia syndrome, postural orthostatic tachycardia, orthostatic intolerance, chronic orthostatic intolerance, dysautonomia, hyperadrenergic POTS, neuropathic POTS, hypovolemic POTS, deconditioning POTS, orthostatic tachycardia

SCOPE: Evaluation and management of POTS in adolescents and adults. Includes diagnostic criteria, autonomic testing, subtype classification (hyperadrenergic, neuropathic, hypovolemic/deconditioning), and pharmacologic/non-pharmacologic treatment. Covers ED presentation for acute decompensation, inpatient management, and outpatient chronic management. Excludes other causes of orthostatic intolerance unless part of differential.

DEFINITIONS: - POTS: Sustained heart rate increase of >=30 bpm (or >=40 bpm in ages 12-19) within 10 minutes of standing or head-up tilt, in the absence of orthostatic hypotension (SBP drop >=20 mmHg), with symptoms present for >=3 months - Hyperadrenergic POTS: Subtype with standing norepinephrine >600 pg/mL; often accompanied by SBP increase >=10 mmHg on standing, tremor, and anxiety - Neuropathic POTS: Subtype associated with peripheral small fiber neuropathy and sudomotor dysfunction; abnormal QSART or skin biopsy - Hypovolemic/Deconditioning POTS: Subtype characterized by low blood volume, low 24-hour urine sodium, and reduced cardiac stroke volume; often associated with prolonged bedrest or deconditioning - Orthostatic intolerance: Symptoms provoked by upright posture (lightheadedness, palpitations, tremulousness, visual blurring, presyncope, cognitive difficulty) relieved by recumbency - Active stand test: Patient stands from supine; HR and BP measured at 1, 3, 5, and 10 minutes; diagnostic if HR increment >=30 bpm (>=40 bpm ages 12-19) without orthostatic hypotension

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

1. LABORATORY WORKUP¶

1A. Core Labs (All Patients)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	STAT	STAT	ROUTINE	STAT	Rule out anemia contributing to tachycardia and orthostatic symptoms	Normal Hgb (>12 g/dL F, >13 g/dL M); no leukocytosis
BMP (CPT 80048) (electrolytes, creatinine, glucose)	STAT	STAT	ROUTINE	STAT	Electrolyte abnormalities causing tachycardia; dehydration; renal function	Normal Na, K, Mg, glucose, creatinine
TSH (CPT 84443)	ROUTINE	ROUTINE	ROUTINE	ROUTINE	Hyperthyroidism as cause of tachycardia and orthostatic symptoms	Normal (0.4-4.0 mIU/L)
Iron studies (CPT 83540, 83550) (serum iron, ferritin, TIBC)	ROUTINE	ROUTINE	ROUTINE	-	Iron deficiency common comorbidity in POTS; contributes to tachycardia	Ferritin >30 ng/mL; serum iron normal
Orthostatic vital signs (active stand test)	STAT	STAT	ROUTINE	-	Diagnostic criterion: HR increment >=30 bpm (>=40 bpm ages 12-19) within 10 min without orthostatic hypotension	HR rise <30 bpm; no SBP drop >=20 mmHg
12-lead ECG (CPT 93000)	STAT	STAT	ROUTINE	STAT	Exclude cardiac arrhythmia, structural disease, pre-excitation, long QT	Normal sinus rhythm; normal intervals; sinus tachycardia expected upright
Urinalysis	ROUTINE	ROUTINE	ROUTINE	-	Screen for UTI, proteinuria, dehydration markers	Normal; specific gravity indicating hydration
Pregnancy test (reproductive-age women)	STAT	STAT	ROUTINE	-	Pregnancy as cause of hemodynamic changes	Negative

1B. Extended Labs (Based on Clinical Suspicion)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
AM cortisol (CPT 82533)	-	ROUTINE	ROUTINE	-	Adrenal insufficiency as cause of orthostatic intolerance	>10 mcg/dL (AM); ACTH stim if borderline
ANA (CPT 86235)	-	ROUTINE	ROUTINE	-	Autoimmune disease screening (Sjogren, lupus associated with autonomic neuropathy)	Negative
Celiac panel (CPT 86364) (tissue transglutaminase IgA)	-	ROUTINE	ROUTINE	-	Celiac disease associated with autonomic neuropathy; common comorbidity	Negative
Serum tryptase (CPT 82785)	-	ROUTINE	ROUTINE	-	Mast cell activation syndrome comorbidity; flushing episodes	Normal (<11.5 ng/mL)
ESR / CRP	-	ROUTINE	ROUTINE	-	Inflammatory or autoimmune process contributing to autonomic dysfunction	Normal
24-hour urine sodium	-	ROUTINE	ROUTINE	-	Assess salt intake adequacy; <170 mEq/day suggests inadequate sodium intake for POTS management	>170 mEq/24hr on therapeutic salt intake
Free T4	-	ROUTINE	ROUTINE	-	Confirm thyroid status if TSH abnormal; thyrotoxicosis workup	Normal (0.8-1.8 ng/dL)
Vitamin B12	-	ROUTINE	ROUTINE	-	B12 deficiency as cause of autonomic neuropathy	>300 pg/mL

1C. Rare/Specialized (Subtype Classification)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Plasma catecholamines (supine and standing) (norepinephrine, epinephrine)	-	EXT	ROUTINE	-	Hyperadrenergic subtype: standing NE >600 pg/mL; ratio standing/supine NE helps classify	Supine NE <400 pg/mL; standing NE <600 pg/mL (hyperadrenergic if standing >600)
Ganglionic acetylcholine receptor antibody (gAChR Ab)	-	-	EXT	-	Autoimmune autonomic ganglionopathy; autoimmune POTS	Negative
Skin biopsy (IENFD, intraepidermal nerve fiber density)	-	-	EXT	-	Neuropathic subtype confirmation; small fiber neuropathy documentation	Normal IENFD for age/sex/site (reduced = neuropathic POTS)
HbA1c	-	ROUTINE	ROUTINE	-	Diabetes as cause of autonomic neuropathy contributing to POTS	<5.7%
Plasma renin activity / aldosterone	-	-	EXT	-	Hyperadrenergic subtype workup; assess renin-aldosterone axis	Normal for posture
Erythropoietin level	-	-	EXT	-	Low erythropoietin associated with hypovolemic POTS	Normal

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential Studies (All Patients)¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Active stand test (10-minute)	STAT	STAT	ROUTINE	-	Immediate; all patients with suspected POTS	HR increment >=30 bpm (>=40 bpm ages 12-19) within 10 min without OH	Acute hemodynamic instability
12-lead ECG (CPT 93000)	STAT	STAT	ROUTINE	STAT	Immediate; all patients	Normal sinus rhythm; exclude arrhythmia, pre-excitation, long QT	None
Continuous cardiac monitoring (telemetry)	STAT	STAT	-	STAT	If admitted; acute tachycardia evaluation	Sinus tachycardia only; no pathologic arrhythmia	None

2B. Extended Studies¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Head-up tilt table test (CPT 95924)	-	-	ROUTINE	-	Outpatient; gold standard for POTS diagnosis if active stand equivocal	HR increment >=30 bpm within 10 min without SBP drop >=20 mmHg; classify response type	Recent MI, severe aortic stenosis, severe CAD
Transthoracic echocardiogram (CPT 93306)	URGENT	ROUTINE	ROUTINE	URGENT	If structural heart disease suspected; palpitations with murmur	Normal LV function; no structural abnormality; normal valves	None
QSART (quantitative sudomotor axon reflex test) (CPT 95923)	-	-	ROUTINE	-	Outpatient autonomic lab; neuropathic subtype evaluation	Normal sudomotor response at all 4 sites; abnormal suggests neuropathic POTS	Skin lesions at test sites
Autonomic reflex screen (Valsalva, deep breathing, tilt) (CPT 95922)	-	-	ROUTINE	-	Comprehensive autonomic testing; subtype classification	Normal heart rate variability; normal Valsalva ratio; intact baroreflex	Recent MI, uncontrolled HTN
Holter monitor (24-48 hour) (CPT 93224)	-	-	ROUTINE	-	If paroxysmal arrhythmia suspected beyond sinus tachycardia	Sinus tachycardia only; no SVT, VT, or high-grade conduction disease	None

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Thermoregulatory sweat test (TST)	-	-	EXT	-	Specialized autonomic lab; suspected widespread autonomic failure	Normal sweat distribution; abnormal pattern suggests autonomic neuropathy	None
MRI brain with/without contrast (CPT 70553)	-	EXT	EXT	-	If central autonomic cause suspected (Chiari, brainstem lesion, MS)	Normal; no Chiari malformation, demyelination, or brainstem pathology	MRI-incompatible devices
MRI cervical spine	-	EXT	EXT	-	If cervical myelopathy or Chiari malformation suspected	Normal; no Chiari, syrinx, or cord compression	MRI-incompatible devices
Blood volume measurement (DAXOR or similar)	-	-	EXT	-	Quantify hypovolemia in suspected hypovolemic subtype	Normal total blood volume; low = hypovolemic POTS	None
Exercise stress test	-	-	EXT	-	Assess exercise capacity; differentiate deconditioning from cardiac limitation	Normal cardiac response; often low peak VO2 in POTS	Acute cardiac disease
Sleep study (polysomnography)	-	-	EXT	-	If comorbid sleep disorder suspected (insomnia, OSA contributing to fatigue)	Normal; no significant sleep-disordered breathing	None

3. TREATMENT¶

3A. Acute/Emergent (ED and Acute Decompensation)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV Normal Saline	IV	Acute POTS decompensation; severe presyncope; dehydration; inability to tolerate oral fluids	1000 mL :: IV :: over 1-2 hr :: 1-2 L NS bolus over 1-2 hours; reassess and repeat if needed; avoid >3 L unless severely dehydrated	Heart failure; volume overload; severe renal failure	Intake/output; HR response; orthostatic vitals post-infusion; signs of overload	STAT	STAT	-	STAT
IV Lactated Ringer	IV	Alternative to NS for volume resuscitation; POTS flare with dehydration	1000 mL :: IV :: over 1-2 hr :: 1-2 L over 1-2 hours; may be better tolerated than NS for repeated infusions	Hyperkalemia; hepatic failure	Intake/output; HR response; electrolytes	STAT	STAT	-	STAT
Trendelenburg position / leg elevation	Physical	Immediate management of acute presyncope or near-syncope	Supine with legs elevated :: Physical :: immediate :: Elevate legs 30-45 degrees immediately; maintain until symptoms resolve; transition to sitting slowly	Respiratory distress; increased ICP	Mental status; HR; BP recovery	STAT	STAT	-	STAT
Telemetry monitoring	Monitoring	Tachycardia evaluation; rule out arrhythmia	Continuous :: Monitoring :: continuous :: Continuous monitoring until sinus tachycardia confirmed and alternative arrhythmias excluded	None	HR; rhythm; arrhythmia detection	STAT	ROUTINE	-	ROUTINE
Oral rehydration (rapid bolus)	PO	Mild-moderate decompensation; oral intake tolerated	500 mL :: PO :: immediate :: Rapid oral hydration with 500 mL electrolyte-containing fluid; repeat as tolerated	Vomiting; inability to swallow	Tolerance; HR response; urine output	STAT	ROUTINE	ROUTINE	-

3B. Non-Pharmacologic Therapies (Foundation of POTS Management)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Increased fluid intake	Dietary	All POTS patients; volume expansion	2-3 L/day :: Dietary :: daily :: Minimum 2-3 L daily fluid intake including water and electrolyte-containing beverages; bolus 500 mL water 15-30 min before prolonged standing	Heart failure; renal failure requiring fluid restriction	Urine output; daily weight; symptom frequency; urine specific gravity	URGENT	ROUTINE	ROUTINE	-
Increased salt intake	Dietary	All POTS patients without contraindication; volume expansion	6-10 g Na/day :: Dietary :: daily :: 6-10 g sodium daily via dietary salt or salt tablets (1 g NaCl tablets, 3-5 tablets TID with meals); titrate to 24-hr urine Na >170 mEq	Uncontrolled HTN; heart failure; severe renal disease	BP; edema; 24-hr urine sodium; syncope frequency	-	ROUTINE	ROUTINE	-
Compression garments	Physical	Venous pooling; orthostatic symptoms; all POTS patients	30-40 mmHg waist-high :: Physical :: daily :: Waist-high compression stockings (30-40 mmHg) preferred over knee-high; abdominal binder (20-40 mmHg) as alternative or adjunct	Peripheral arterial disease; skin breakdown	Skin integrity; compliance; symptom improvement	-	ROUTINE	ROUTINE	-
Graduated exercise program (Levine/CHOP protocol)	Physical	All POTS patients; deconditioning reversal; cornerstone of long-term management	30 min 3-4x/week :: Physical :: 3-4x/week :: Start recumbent exercise (rowing, swimming, recumbent bike) 30 min 3-4x/week; increase gradually over 3-6 months to upright aerobic exercise; avoid sudden upright exercise initially	Acute decompensation; unstable cardiac disease	Exercise tolerance; resting HR trend; orthostatic symptoms; functional capacity	-	-	ROUTINE	-
Counter-pressure maneuvers	Physical	Prodromal symptoms; prevention of presyncope	Perform at onset of prodrome :: Physical :: PRN :: Leg crossing with muscle tensing; squatting; handgrip; lower body muscle pumping; can abort ~40% of presyncopal episodes	None	Symptom diary; effectiveness	URGENT	ROUTINE	ROUTINE	-
Head-of-bed elevation	Physical	Nocturnal polyuria reduction; improve morning orthostatic tolerance	10-20 degree elevation :: Physical :: nightly :: Elevate head of bed 4-6 inches (blocks or wedge); reduces nocturnal natriuresis and supine hypertension	None	Morning symptoms; nocturia frequency	-	ROUTINE	ROUTINE	-

3C. First-Line Pharmacotherapy¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Fludrocortisone	PO	Volume expansion; first-line for hypovolemic/general POTS	0.05 mg daily; 0.1 mg daily; 0.2 mg daily :: PO :: daily :: Start 0.05-0.1 mg daily; titrate by 0.05 mg q1-2 weeks; max 0.2 mg daily; takes 1-2 weeks for full effect	Heart failure; uncontrolled HTN; hypokalemia	K+ q2-4 weeks during titration then q3-6 months; supine BP; weight; edema; headache	-	ROUTINE	ROUTINE	-
Midodrine	PO	Peripheral vasoconstriction; orthostatic symptoms refractory to non-pharmacologic measures	2.5 mg TID; 5 mg TID; 10 mg TID :: PO :: TID :: Start 2.5 mg TID (upon waking, midday, mid-afternoon); titrate by 2.5 mg q1 week; max 10 mg TID; last dose >=4 hours before bedtime	Supine hypertension (SBP >180); urinary retention; pheochromocytoma; severe cardiac disease; thyrotoxicosis	Supine BP (avoid >160/90); urinary symptoms; piloerection (scalp tingling); HR	-	ROUTINE	ROUTINE	-
Propranolol (low-dose)	PO	Heart rate control; hyperadrenergic symptoms (palpitations, tremor, anxiety)	10 mg BID; 10 mg TID; 20 mg TID :: PO :: BID-TID :: Start 10 mg BID-TID; titrate slowly; max 20 mg TID; low doses preferred in POTS (high doses worsen fatigue/exercise intolerance)	Asthma; severe bradycardia; 2nd/3rd degree AV block; decompensated HF; severe hypotension	HR (target standing HR <100, avoid resting <60); BP; fatigue; exercise tolerance	-	ROUTINE	ROUTINE	-
Ivabradine (Corlanor)	PO	Heart rate reduction without BP lowering; POTS with inappropriate sinus tachycardia; beta-blocker intolerant	2.5 mg BID; 5 mg BID; 7.5 mg BID :: PO :: BID :: Start 2.5 mg BID with meals; titrate by 2.5 mg q2 weeks; max 7.5 mg BID; selective If-channel blocker	Severe hepatic impairment; sick sinus syndrome (without pacemaker); SA block; 3rd degree AV block; resting HR <60 bpm; concurrent strong CYP3A4 inhibitors	HR (target resting 60-80); visual phenomena (phosphenes); BP; atrial fibrillation	-	-	ROUTINE	-
Pyridostigmine (Mestinon)	PO	Augment ganglionic neurotransmission; milder POTS; avoid BP effects	30 mg TID; 60 mg TID :: PO :: TID :: Start 30 mg TID; may increase to 60 mg TID; enhances autonomic ganglionic transmission without significant supine hypertension	Mechanical bowel or urinary obstruction; bradycardia; asthma (relative)	GI side effects (nausea, diarrhea, cramping); HR; cholinergic symptoms	-	-	ROUTINE	-

3D. Second-Line/Refractory Therapies¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Clonidine	PO	Hyperadrenergic POTS with elevated standing NE; refractory tachycardia with hypertension	0.05 mg BID; 0.1 mg BID; 0.1 mg TID :: PO :: BID-TID :: Start 0.05 mg BID; titrate by 0.05 mg q1 week; max 0.3 mg/day divided; central alpha-2 agonist reduces sympathetic outflow; do NOT discontinue abruptly (rebound hypertension)	Severe bradycardia; hypotension	BP; HR; sedation; dry mouth; rebound HTN with abrupt discontinuation	-	-	ROUTINE	-
Methyldopa	PO	Hyperadrenergic POTS refractory to clonidine; standing hypertension with tachycardia	125 mg BID; 250 mg BID :: PO :: BID :: Start 125 mg BID; titrate slowly; max 500 mg BID; false neurotransmitter reduces sympathetic tone	Hepatic disease; active liver disease; history of methyldopa-associated hepatitis; MAOIs	LFTs at baseline and 6-12 weeks; CBC (hemolytic anemia); BP; sedation; Coombs test if anemia	-	-	EXT	-
Desmopressin (DDAVP)	PO/Intranasal	Hypovolemic POTS with nocturnal polyuria; acute volume expansion	0.1 mg PO qHS; 0.2 mg PO qHS :: PO :: qHS :: Start 0.1 mg PO at bedtime; may increase to 0.2 mg; alternative: 10 mcg intranasal qHS; retain free water overnight	Hyponatremia; primary polydipsia; HF; habitual/psychogenic polydipsia	Serum sodium (check within 1 week of initiation then monthly); fluid balance; morning weight; headache	-	-	EXT	-
Droxidopa (Northera)	PO	Neurogenic orthostatic component; neuropathic POTS with norepinephrine deficiency	100 mg TID; 200 mg TID; 300 mg TID; 600 mg TID :: PO :: TID :: Start 100 mg TID; titrate by 100 mg TID q24-48h; max 600 mg TID; norepinephrine prodrug	Supine hypertension; concurrent catecholamine drugs (MAOIs, SNRIs at high dose)	Supine BP (avoid >180/110); HR; syncope frequency; headache	-	-	ROUTINE	-
Octreotide	SQ	Refractory POTS with splanchnic vasodilation; postprandial worsening	25 mcg SQ BID; 50 mcg SQ BID; 100 mcg SQ TID :: SQ :: BID-TID :: Start 25 mcg SQ BID pre-meals; titrate to 50-100 mcg TID; reduces splanchnic blood pooling	Gallstones (relative); diabetes (alters glucose); hypersensitivity	Blood glucose; GI symptoms (nausea, diarrhea, abdominal pain); gallbladder ultrasound q12 months	-	-	EXT	-
Modafinil	PO	POTS-associated fatigue and cognitive dysfunction ("brain fog") refractory to other measures	100 mg daily; 200 mg daily :: PO :: daily :: Start 100 mg daily in AM; may increase to 200 mg daily; wakefulness-promoting agent	Severe hepatic impairment; history of left ventricular hypertrophy; mitral valve prolapse with prior CNS stimulant use	BP; HR; sleep quality; psychiatric symptoms; headache	-	-	EXT	-
Erythropoietin (EPO)	SQ	Severe hypovolemic POTS with documented low red cell mass and low EPO level	10,000 units SQ weekly; 20,000 units SQ weekly :: SQ :: weekly :: 10,000-20,000 units SQ weekly; titrate to Hgb 12-14 g/dL; requires documented low EPO level and low blood volume	Uncontrolled HTN; history of thromboembolic events; polycythemia	Hgb/Hct q2-4 weeks; BP; iron studies; thrombotic events; reticulocyte count	-	-	EXT	-
IV saline infusions (scheduled outpatient)	IV	Refractory POTS with recurrent severe decompensation unresponsive to oral volume expansion and pharmacotherapy	1000 mL NS :: IV :: weekly-biweekly :: 1 L NS infusion weekly or biweekly in infusion center; last resort; evidence limited	Heart failure; renal failure; adequate response to oral measures (not first-line)	Electrolytes; BP; HR; volume status; infection risk at access site	-	-	EXT	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Autonomic disorders specialist/neurologist for formal autonomic testing (tilt table, QSART, Valsalva), subtype classification, and chronic management guidance	-	ROUTINE	ROUTINE	-
Cardiology consultation to exclude structural heart disease, arrhythmia, or inappropriate sinus tachycardia as alternative diagnosis	URGENT	ROUTINE	ROUTINE	URGENT
Physical therapy/exercise physiology referral for structured graduated exercise program (Levine or CHOP protocol) tailored to POTS patients starting with recumbent exercise	-	ROUTINE	ROUTINE	-
Rheumatology if joint hypermobility spectrum disorder or Ehlers-Danlos syndrome suspected, given high comorbidity with POTS	-	-	ROUTINE	-
Allergy/Immunology if mast cell activation syndrome suspected (flushing, urticaria, anaphylaxis, elevated tryptase with POTS symptoms)	-	-	ROUTINE	-
Gastroenterology if significant GI dysmotility (gastroparesis, nausea, constipation) contributing to dehydration and nutritional compromise	-	ROUTINE	ROUTINE	-
Psychiatry/Psychology for comorbid anxiety, depression, or functional overlay; cognitive behavioral therapy for symptom coping strategies	-	-	ROUTINE	-
Sleep medicine referral if comorbid insomnia or sleep-disordered breathing contributing to fatigue and autonomic dysfunction	-	-	EXT	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD	ICU
Drink at least 2-3 liters of fluid daily including water and electrolyte-containing beverages; rapid bolus of 500 mL water before prolonged standing (acutely raises BP via osmopressor reflex)	STAT	ROUTINE	ROUTINE	-
Increase dietary sodium to 6-10 grams daily using salt tablets or dietary salt (unless contraindicated by hypertension or heart failure) to expand plasma volume	-	ROUTINE	ROUTINE	-
Wear waist-high compression stockings (30-40 mmHg) during all upright activity; use abdominal binder as alternative or adjunct to reduce splanchnic pooling	-	ROUTINE	ROUTINE	-
Avoid prolonged standing; if standing is required, shift weight, cross legs, and tense muscles to promote venous return	URGENT	ROUTINE	ROUTINE	-
Rise slowly from lying to sitting to standing with 1-2 minutes at each position to allow hemodynamic adjustment	URGENT	ROUTINE	ROUTINE	-
Recognize warning symptoms (lightheadedness, tunnel vision, palpitations) and immediately sit or lie down to prevent syncope and injury	STAT	ROUTINE	ROUTINE	-
Avoid triggers: hot environments, large carbohydrate-heavy meals, alcohol, prolonged hot showers/baths, rapid positional changes	-	ROUTINE	ROUTINE	-
Return to ED if syncopal episode occurs, chest pain develops, new neurological symptoms appear, or symptoms acutely worsen despite home measures	STAT	-	ROUTINE	-

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD	ICU
Begin structured graduated exercise program (Levine/CHOP protocol): start with recumbent exercise 30 min 3-4x/week, progress to upright over 3-6 months; exercise is the single most effective long-term intervention for POTS	-	ROUTINE	ROUTINE	-
Eat small, frequent meals rather than large meals to reduce postprandial blood pooling in the splanchnic circulation	-	ROUTINE	ROUTINE	-
Avoid excessive alcohol which causes vasodilation and worsens orthostatic intolerance	-	ROUTINE	ROUTINE	-
Maintain consistent sleep schedule with 7-9 hours nightly; sleep with head of bed elevated 4-6 inches to reduce nocturnal natriuresis	-	ROUTINE	ROUTINE	-
Avoid medications that worsen POTS: diuretics, vasodilators, tricyclic antidepressants (orthostatic effect), stimulants at high dose; review all medications with prescriber	-	ROUTINE	ROUTINE	-
Use cooling strategies for heat sensitivity: cooling vest, cold water intake, portable fan, avoiding prolonged heat exposure	-	ROUTINE	ROUTINE	-
Obtain medical alert identification for patients with frequent presyncope/syncope to inform first responders of POTS diagnosis	-	-	ROUTINE	-
Prioritize mental health self-care: POTS is a chronic condition; pace activities, practice stress management, and engage support groups to improve quality of life	-	-	ROUTINE	-

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Inappropriate sinus tachycardia (IST)	Elevated resting HR (>100 bpm) in supine AND upright; not posturally triggered; no orthostatic symptoms	24-hour Holter showing elevated HR at rest; HR does not normalize when supine
Orthostatic hypotension (neurogenic)	SBP drop >=20 mmHg or DBP drop >=10 mmHg within 3 min of standing; HR may rise but BP falls significantly	Active stand test or tilt table showing BP drop meeting OH criteria
Pheochromocytoma / paraganglioma	Episodic hypertension, diaphoresis, headache, tachycardia; not postural-dependent	24-hour urine catecholamines/metanephrines; plasma free metanephrines; adrenal imaging
Hyperthyroidism	Resting tachycardia; heat intolerance; weight loss; tremor; not position-dependent	TSH (suppressed); free T4 (elevated); thyroid antibodies
Anemia (moderate-severe)	Tachycardia and orthostatic symptoms that resolve with correction; pallor; dyspnea	CBC showing Hgb <10 g/dL; symptoms resolve with transfusion/iron
Anxiety/panic disorder	Tachycardia with situational triggers (not postural); chest tightness; hyperventilation; paresthesias	Normal active stand test; symptoms reproduce with hyperventilation but not posture alone
Cardiac arrhythmia (SVT, atrial fibrillation)	Sudden onset tachycardia not related to posture; irregular rhythm; very rapid rates (>150 bpm)	ECG showing non-sinus rhythm; Holter or event recorder capturing arrhythmia
Dehydration / hypovolemia (acute)	Tachycardia and orthostatic symptoms that fully resolve with volume repletion; identifiable cause	History (GI illness, poor intake); labs showing hemoconcentration; resolution with IV fluids
Addison disease (adrenal insufficiency)	Orthostatic hypotension (not just tachycardia); hyperpigmentation; hyponatremia; hyperkalemia; fatigue	AM cortisol <3 mcg/dL; ACTH stimulation test; ACTH level
Mast cell activation syndrome (MCAS)	Flushing, urticaria, GI symptoms, tachycardia; may coexist with POTS; episodic	Serum tryptase during episode; 24-hr urine histamine metabolites; prostaglandin D2
Ehlers-Danlos syndrome (hypermobile type)	Joint hypermobility; soft/stretchy skin; easy bruising; frequently comorbid with POTS rather than differential	Beighton score >=5; clinical criteria (2017 EDS classification); genetic testing for vascular type
Medication-induced tachycardia	Temporal relationship to medication initiation; common offenders: stimulants, decongestants, bronchodilators, thyroid supplements	Medication reconciliation; improvement with dose reduction or discontinuation

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Orthostatic vital signs (HR and BP at 1, 3, 5, 10 min standing)	Each encounter; q8h if admitted	Standing HR increment <30 bpm; no OH	Optimize volume/salt; adjust medications; reassess subtype	STAT	ROUTINE	ROUTINE	-
Resting heart rate	Each encounter	60-90 bpm supine	Adjust beta-blocker or ivabradine dose; evaluate for over-treatment if <55 bpm	STAT	ROUTINE	ROUTINE	STAT
Serum potassium	Baseline; q2-4 weeks during fludrocortisone titration; then q3-6 months	K+ 3.5-5.0 mEq/L	Supplement potassium if <3.5; reduce fludrocortisone dose	-	ROUTINE	ROUTINE	-
Supine blood pressure	Each encounter; home monitoring	SBP <160 mmHg supine	Reduce midodrine dose; time last dose >=4 hr before bed; add clonidine qHS if persistent	-	ROUTINE	ROUTINE	-
Serum sodium	Baseline; within 1 week of desmopressin initiation; monthly on desmopressin	Na 135-145 mEq/L	Hold desmopressin if Na <135; restrict free water; recheck in 48 hours	-	ROUTINE	ROUTINE	STAT
24-hour urine sodium	Baseline then q3-6 months	>170 mEq/24hr on therapeutic salt intake	Increase salt supplementation; dietary counseling; reassess compliance	-	-	ROUTINE	-
Syncope/presyncope frequency	Each visit; patient diary	Decreasing trend; target <1 episode/month	Reassess treatment; change medication; evaluate compliance	STAT	ROUTINE	ROUTINE	-
Exercise tolerance (functional capacity)	Q3-6 months	Improving exercise duration and intensity	Modify exercise program; reassess medications; evaluate deconditioning	-	-	ROUTINE	-
Weight and volume status	Each encounter	Stable weight; no edema	Adjust fludrocortisone; fluid intake; add diuretic if needed for edema	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge from ED	Confirmed POTS exacerbation with HR response to IV fluids; stable orthostatic vitals post-hydration; no syncope in ED; cardiac arrhythmia excluded; tolerating oral fluids; reliable outpatient follow-up arranged
Observation (ED short stay)	POTS flare requiring IV hydration with incomplete symptom resolution; awaiting initial cardiac workup (ECG, troponin, echo); first-time presentation requiring diagnostic evaluation
Admit to floor	Severe decompensation with recurrent presyncope/syncope despite IV fluids; unable to tolerate oral intake; need for telemetry to exclude arrhythmia; new-onset POTS requiring inpatient autonomic workup; comorbid condition requiring inpatient management
Admit to ICU/monitored bed	Hemodynamic instability not responding to volume resuscitation; sustained HR >150 bpm with concern for arrhythmia; syncope with injury requiring monitoring; concurrent critical illness triggering POTS decompensation
Outpatient follow-up (autonomic specialist)	All newly diagnosed POTS: autonomic neurology within 2-4 weeks; established POTS with stable management: q3-6 months; post-medication titration: 2-4 weeks
Outpatient follow-up (PCP/cardiology)	Medication monitoring q2-4 weeks during titration; stable patients q3-6 months; annual echocardiogram if structural concern; exercise program reassessment q3 months

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Diagnostic criteria: HR increment >=30 bpm within 10 min of standing without orthostatic hypotension	Consensus, Level C	Raj SR. Circulation 2013
Tilt table testing as diagnostic standard for POTS	Class IIa, Level B	Sheldon RS et al. Heart Rhythm 2015
Graduated exercise training (Levine protocol) improves POTS symptoms and cardiovascular fitness	Class I, Level B	Fu Q et al. J Am Coll Cardiol 2010
Fludrocortisone for volume expansion in POTS	Class IIa, Level C	Raj SR et al. Circulation 2005
Midodrine reduces orthostatic tachycardia and improves standing tolerance	Class IIa, Level B	Raj SR et al. Circulation 2005
Ivabradine reduces heart rate and improves symptoms in POTS	Class IIa, Level B	Taub PR et al. J Am Coll Cardiol 2021
Pyridostigmine improves symptoms with minimal supine hypertension	Class IIa, Level B	Raj SR et al. Circulation 2005
ACC Expert Consensus Statement on POTS and autonomic disorders	Consensus	Vernino S et al. Auton Neurosci 2021
Hyperadrenergic subtype classification by standing norepinephrine	Class IIa, Level C	Goldstein DS et al. Circulation 2002
Compression garments reduce venous pooling and improve orthostatic tolerance	Class IIa, Level B	Figueroa JJ et al. Arch Phys Med Rehabil 2015
Small fiber neuropathy in neuropathic POTS subtype	Class IIa, Level C	Gibbons CH, Freeman R. Neurology 2009
Salt and fluid intake of 2-3 L/day and 6-10 g Na/day as first-line nonpharmacologic therapy	Consensus, Level C	Raj SR. Circulation 2013

NOTES¶

POTS predominantly affects women (5:1 ratio) aged 15-50 years; onset often follows viral illness, surgery, pregnancy, or trauma
Diagnosis requires symptoms to be present for >=3 months to distinguish from transient post-illness orthostatic tachycardia
POTS is NOT a diagnosis of exclusion; it requires meeting specific hemodynamic criteria on active stand or tilt table testing
Common comorbidities include Ehlers-Danlos syndrome (hypermobile type), mast cell activation syndrome, small fiber neuropathy, chronic fatigue, and migraine
Non-pharmacologic measures (fluids, salt, compression, exercise) are the foundation and should be maximized before pharmacotherapy
Low-dose beta-blockers are preferred; high doses worsen fatigue and exercise intolerance
Ivabradine is increasingly used as first-line for rate control due to favorable side effect profile and lack of hypotensive effect
Hyperadrenergic subtype responds best to central sympatholytics (clonidine, methyldopa) and low-dose beta-blockers
Deconditioning is both a cause and consequence of POTS; structured exercise is the most effective long-term intervention
Avoid iatrogenic harm: excessive IV fluids, unnecessary beta-blocker doses, or labeling as anxiety/panic disorder without proper autonomic testing
Many patients require combination therapy targeting multiple pathophysiologic mechanisms

CHANGE LOG¶

v1.1 (February 8, 2026) - Structured dosing: populated frequency field (3rd :: field) across all treatment rows in 3A, 3B, 3C, 3D - Setting coverage: upgraded Iron studies from "-" to ROUTINE in ED (relevant to tachycardia workup) - Setting coverage: upgraded Celiac panel from "-" to ROUTINE in HOSP - Setting coverage: upgraded 24-hour urine sodium from "-" to ROUTINE in HOSP - Setting coverage: upgraded Vitamin B12 from "-" to ROUTINE in HOSP - Added ICU column to Sections 4B and 4C for format consistency with 4A - Fixed Telemetry route column from "-" to "Monitoring" (appropriate descriptor) - Standardized IV fluid dosing format in 3A (consolidated dose options into structured format) - Directive language: changed "Consider medical alert identification" to "Obtain medical alert identification" - Directive language: changed "Cooling strategies for heat sensitivity" to "Use cooling strategies" - Directive language: changed "Mental health self-care" to "Prioritize mental health self-care" - Directive language: removed "consider" from monitoring actions (Section 6) - Cleaned up Clonidine contraindications to include abrupt discontinuation warning in dosing field - Updated version to 1.1

v1.0 (February 8, 2026) - Initial template creation - Comprehensive coverage including diagnostic criteria, subtype classification, and multi-setting management - 13 medications with individual treatment rows and structured dosing format - Non-pharmacologic therapies section with exercise program recommendations - Subtype-specific testing: plasma catecholamines, QSART, skin biopsy, blood volume measurement - Evidence references with PubMed links (Raj 2013, Sheldon 2015, Vernino 2021, Fu 2010, Taub 2021) - Disposition criteria for ED, observation, floor, ICU, and outpatient follow-up