Ajax Harwood Clinic

POTS: should I be tested?

Last reviewed 2026-09-23Content v0760034d1984
Reference tool — not medical advice. Clinician judgement always required.

Postural orthostatic tachycardia syndrome (POTS)

Clinical diagnosis — no single test

Also called: POTS, postural tachycardia syndrome, dysautonomia, orthostatic intolerance

Patients raise POTS after searching online for lightheadedness, a racing heart, or fainting when they stand, sometimes prompted by a smartwatch heart-rate alert, an ND, or a social-media community describing symptoms much like their own. Awareness has grown sharply since the COVID-19 pandemic, since infection is a recognized trigger. The label often fits: POTS is a real, under-recognized condition, and the symptoms driving the search are genuine.

Raises suspicion

  • • Heart rate rising by 30 beats per minute or more within 10 minutes of standing (40 bpm or more for ages 12-19), without a substantial drop in blood pressure [1]
  • • Lightheadedness, palpitations, tremor, or visual graying-out that is clearly worse standing and better lying down
  • • Reduced exercise tolerance or fatigue that tracks with time spent upright, present for several months
  • • Onset after a triggering illness (including COVID-19), pregnancy, surgery, or a period of prolonged bed rest

Does not raise suspicion

  • • A single episode of feeling lightheaded on standing up quickly
  • • Fatigue or brain fog with a normal heart-rate response to standing
  • • Occasional palpitations with no clear link to posture

Red flags

  • • Syncope (fainting) triggered by exertion, rather than by prolonged standing
  • • Chest pain accompanying the palpitations
  • • A family history of sudden cardiac death: needs cardiology assessment before assuming POTS

Who to test

  • Anyone with symptoms of orthostatic intolerance (lightheadedness, palpitations, fatigue worse on standing)A 10-minute active stand test (lying or sitting for 5-10 minutes, then standing, with heart rate and blood pressure checked at 0, 1, 3, 5 and 10 minutes) can be done right in the office; no TestSelect entry, since it is a bedside vital-signs protocol, not a lab test. Tilt-table testing is not required for most patients [1].
  • Excessive orthostatic tachycardia confirmed, before attributing it to POTS: Complete blood count (CBC) (Situation-specific), TSH (thyroid stimulating hormone) (Standard), Electrolytes (sodium, potassium, chloride, bicarbonate) (Situation-specific), Ferritin (Standard)Basic bloodwork to look for common contributors and mimics: anemia, thyroid disease, dehydration or electrolyte disturbance, and iron deficiency.
  • Red flags present (exertional syncope, chest pain, family history of sudden cardiac death)ECG and cardiology referral first (no TestSelect entry for ECG); do not assume POTS until a cardiac cause is excluded.

More likely instead

  • • dehydration
  • • deconditioning (including post-viral or post-bedrest)
  • • medication effects (e.g., diuretics, alpha-blockers)
  • • anxiety
  • • Iron deficiency without anemia
  • • Hypothyroidism (see the thyroid page)
  • • ME/CFS (frequently overlaps with POTS)

Counselling script

“If your heart rate rises by 30 beats a minute or more within 10 minutes of standing, without your blood pressure dropping, and this has gone on for months, POTS is a reasonable diagnosis after a stand test and basic bloodwork. Without that pattern, we should look at other explanations like dehydration, deconditioning, or thyroid disease first. If you've fainted during exercise or have chest pain, we need to rule out a heart problem before anything else.”

Chart snippet (OSCAR-safe plain text)

Concern discussed, not tested

Concern re: POTS (postural orthostatic tachycardia syndrome) discussed, raised by patient or ND.
Discriminating features: sustained heart rate rise on standing, symptom duration, red flags for cardiac cause; reviewed.
Assessment: criteria for POTS not yet confirmed in office.
Plan: 10-minute active stand test planned; alternative causes of fatigue and orthostatic symptoms discussed.
Ref: Canadian Cardiovascular Society POTS position statement 2020.
Patient given info page: https://pots.ajaxharwoodclinic.com/patient
Revisit if: fainting with exertion, chest pain, or new red-flag features develop.

Testing ordered

Concern re: POTS discussed.
Discriminating features: heart rate rise of 30 bpm or more within 10 minutes of standing, without substantial blood pressure drop; symptoms present several months.
Assessment: findings support a POTS work-up.
Plan: 10-minute active stand test performed in office; CBC, TSH, electrolytes and ferritin ordered to exclude secondary causes.
Ref: Canadian Cardiovascular Society POTS position statement 2020.
Patient given info page: https://pots.ajaxharwoodclinic.com/patient
Revisit if: symptoms persist despite standard measures, or red-flag features develop.

Revisit if

  • • Fainting triggered by exertion
  • • New chest pain
  • • Symptoms not improving with standard measures (fluids, salt, compression, graded exercise)
  • • A new family history of sudden cardiac death comes to light

References

  1. 1. Canadian Cardiovascular Society. Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance (2020)Diagnostic criteria for POTS: sustained heart-rate increase of at least 30 bpm (40 bpm for ages 12-19) within 10 minutes of standing, without substantial orthostatic hypotension
Evidence notes

Tag rationale: B, per batch instruction, not borderline. POTS has objective, quantitative diagnostic criteria (heart-rate response to standing) but diagnosis still requires the whole clinical picture, chronic symptoms of orthostatic intolerance plus exclusion of other causes, assessed with a bedside test rather than a single confirmatory lab value, which is why this is tagged B rather than A alongside conditions like hypothyroidism. The CCS position statement [1] was retrieved via Crossref and the PubMed/eutils abstract this session; the journal's own fulltext page returned HTTP 403 to automated fetch, so this session did not independently confirm the exact minimum symptom-duration threshold (commonly cited elsewhere as 3 or 6 months) from the statement's full text -- flagged here as an honest gap rather than asserted in raises_suspicion. Secondary-cause screening bloodwork (CBC, TSH, electrolytes, ferritin) reflects standard clinical practice for an orthostatic-intolerance work-up and is not independently sourced to the CCS abstract this session.

General clinical reference for Ajax Harwood Clinic. Not medical advice, and not a substitute for individualized clinical assessment.