POTS Explained: Understanding Postural Orthostatic Tachycardia Syndrome

Based on a conversation with Dominic Coe

There are some conditions that remain invisible until they are impossible to ignore.

A person stands up and suddenly feels dizzy. Their heart races. Their vision narrows. They feel shaky, nauseated, drained, or on the verge of fainting. Sometimes it happens after standing. Sometimes after exercise. Sometimes after a meal. Sometimes after an illness. And often, before anyone explains what is happening, they are told some version of the same thing: drink more water, eat more salt, and try not to worry.

For some people, those suggestions help. For others, they barely scratch the surface.

This is part of what makes Postural Orthostatic Tachycardia Syndrome, or POTS, so frustrating. It is real, often debilitating, and deeply multi-systemic. Yet it can still be misunderstood, underdiagnosed, or reduced to a narrow set of symptoms without sufficient attention to the person living through it.

Understanding POTS requires more than memorizing a definition. It requires recognizing that what looks like a heart issue may involve the nervous system, blood volume regulation, vascular tone, immune function, connective tissue, digestion, exercise tolerance, and even post-viral changes.

What is POTS?

POTS stands for Postural Orthostatic Tachycardia Syndrome. At its most basic level, it is an autonomic condition characterized by an excessive increase in heart rate when a person moves to an upright posture.

In adults, the classic diagnostic threshold is a heart rate increase of at least 30 beats per minute within 10 minutes of standing. In adolescents, the threshold is generally 40 beats per minute. This occurs without the clear orthostatic hypotension that would otherwise explain the symptoms. In other words, blood pressure may not show the dramatic drop you might expect, even though the person feels profoundly unwell.

That detail matters because it highlights one of the most confusing aspects of POTS. A patient can present with severe dizziness, presyncope, syncope, palpitations, or exercise intolerance, and yet standard metrics may not immediately tell the full story.

POTS is called a syndrome for a reason. It is not one singular disease process with one singular cause. It is a cluster of symptoms and physiological patterns that may arise from different underlying contributors.

More than a fast heart rate

The heart rate change is the hallmark, but it is far from the whole picture.

People with POTS may experience dizziness, fainting, tremors, migraines, anxiety, chest discomfort, heat intolerance, nausea, bloating, constipation, diarrhea, early fullness during meals, exercise intolerance, palpitations, fatigue, poor coordination, joint pain, and delayed recovery after activity. Some patients also report skin changes, flushing, shortness of breath, and symptoms that resemble heightened histamine responses or inflammatory reactivity.

This broad symptom profile is part of why POTS can be so confusing. It does not fit neatly into one specialty. It can look cardiovascular, neurological, gastrointestinal, musculoskeletal, immunological, or psychological depending on which symptoms are most prominent.

That does not mean it is vague or imaginary. It means it is complex.

Why POTS can be difficult to diagnose

One reason POTS often takes time to diagnose is that its symptoms can overlap with so many other conditions. Dizziness can be blamed on dehydration. Palpitations can be attributed to anxiety. Fatigue can be written off as stress. Gastrointestinal symptoms may be sent down a separate pathway entirely. Joint instability may be treated as an orthopedic issue without recognizing the autonomic component.

This is why a careful history matters so much. The question is not only whether a person gets dizzy. The question is when, how, under what circumstances, and alongside what other symptoms.

Patterns begin to matter. Does the person feel worse after standing for long periods? Do they struggle with heat? Do large meals worsen symptoms? Do they have a history of fainting, hypermobility, migraines, or autoimmune disease? Did symptoms worsen after a viral illness? Does exertion leave them unusually depleted?

POTS often emerges more clearly when clinicians stop looking for a single isolated complaint and begin paying attention to systems.

The autonomic nervous system is central

At the core of POTS is autonomic dysregulation.

The autonomic nervous system governs the things we do not consciously control. Heart rate. Blood vessel tone. Digestion. Temperature regulation. Fluid balance. Many patients with POTS seem to have a system that struggles to adapt efficiently to posture and internal demands.

When a healthy person stands up, the body compensates quickly. Vessels constrict where needed. Blood redistributes. Perfusion to the brain is maintained. The person remains stable.

In POTS, that response appears impaired or inefficient. The heart may race to compensate for what the rest of the system is not regulating well. Some patients experience blood pooling, especially in the lower body or gastrointestinal system. Others appear to have abnormalities in sympathetic and parasympathetic tone. Some may have low blood volume. Some may have overlapping vascular, neurological, or immune-related factors that change how the system responds to being upright.

The result is not simply inconvenience. It can be a real loss of confidence in daily life. Standing, walking, training, driving, showering, and eating can all begin to feel uncertain.

POTS and hypermobility

One of the more interesting relationships in the research is the connection between POTS and hypermobile Ehlers-Danlos syndrome.

Hypermobility alone does not mean someone has POTS, and POTS alone does not mean someone has hypermobile EDS. But the overlap is significant enough that clinicians should be paying attention.

One proposed explanation is vascular elasticity. If connective tissue is more lax, blood vessels may not constrict as effectively, making blood pooling more likely when posture changes. That may help explain why some hypermobile patients experience dizziness, fatigue, presyncope, and exercise intolerance.

This relationship matters because it changes what we look for clinically. A patient with POTS symptoms and a history of frequent sprains, joint instability, poor proprioception, and delayed recovery may need more than simple hydration advice. They may need a broader connective tissue and neuromuscular lens as well.

POTS after viral illness and the COVID era

Another major area of interest is the rise in POTS-like presentations after viral illness, especially since the COVID era.

Many clinicians began noticing a sharp increase in dysautonomia, exercise intolerance, fainting, palpitations, and postural symptoms in people who had not previously struggled with them. Some of these patients appeared to develop clear POTS syndromes after infection. This has led to growing discussion around post-viral autonomic dysfunction, inflammatory responses, endothelial changes, receptor interactions, and altered fluid or vascular regulation.

While the mechanisms are still being explored, the larger point is difficult to ignore. Some people who were functioning normally before illness are now struggling with symptoms that significantly alter daily life.

For providers, that means history matters again. A patient’s timeline may tell you more than a single test. If symptoms appeared or worsened after a major viral illness, that may become a useful part of the clinical picture.

POTS is not just cardiovascular

One of the most helpful mindset shifts for understanding POTS is realizing that it is not merely a “heart problem.”

Yes, the tachycardia is a defining feature. Yes, cardiology involvement is important. Red flags must be ruled out. Dangerous arrhythmias, structural pathology, and other serious causes of syncope need proper evaluation.

But once those are addressed, the conversation often needs to expand.

POTS may involve the heart, but it also often involves the vessels, the autonomic nervous system, blood volume regulation, gastrointestinal physiology, inflammatory patterns, connective tissue behavior, and exercise adaptation. This is why a single specialty, acting in isolation, may miss part of what the patient needs.

Some patients benefit from cardiology oversight, functional neurology, graded exercise, nutritional intervention, electrolyte support, rehabilitation, and broader co-management all at once.

Complex cases often require collaborative care.

What conservative management often looks like

While severe or atypical cases may require more intensive medical evaluation, many patients benefit from a practical foundation of conservative care.

Hydration is one of the first pillars. Many patients need significantly more water than the average person, often in the range of two to three liters per day, depending on the case. Electrolytes matter too, especially sodium. Not because sodium is suddenly “healthy” in a simplistic sense, but because volume regulation and symptom stability may improve when the body is better supported.

Compression can also help, especially for those dealing with blood pooling. Compression garments for the lower extremities or abdomen may reduce symptom burden in upright positions.

Nutrition matters as well. Some patients feel worse after large meals, likely due to increased blood flow demands in digestion. Smaller meals, slower eating, and nutrient-dense options that are easier to digest may be more tolerable. In some cases, broth-based meals or stews may be especially helpful because they combine hydration, minerals, and digestibility.

These strategies are not glamorous, but for many patients they are meaningful.

Exercise is essential, but it must be dosed wisely

One of the most important conversations around POTS is exercise.

At first glance, exercise intolerance may make training sound like the wrong prescription. But over time, strategic exercise is often one of the most valuable long-term tools available.

The challenge is dose.

POTS patients should not be thrown into aggressive conditioning programs and told to push through it. That is not graded exposure. That is poor programming. Instead, exercise should be introduced in a way that respects symptom thresholds while gradually improving cardiovascular efficiency, vascular support, and tolerance to position changes.

In many cases, this means starting lower and slower than the patient expects. Short bouts. Recumbent or supported positions when needed. Isometric work for the lower body. Gradual aerobic exposure. Careful monitoring of symptom response during and after sessions.

The goal is not simply burning calories or “getting in shape.” The goal is teaching the system that it can become upright, move, circulate blood, and exert effort without triggering alarm every time.

Done well, exercise is not just training. It is retraining.

Why graded exposure matters

The nervous system learns from repetition.

If every upright position or exercise bout ends in distress, the body may become more guarded and anticipatory over time. But if movement is introduced gradually, safely, and repeatedly within tolerable ranges, the body can begin building trust again.

This is one reason knowledgeable coaching and rehabilitation matter so much in POTS. The right provider is not only someone who knows what POTS is. It is someone who knows how to scale effort, watch for warning signs, and help the patient make progress without repeatedly crashing them.

There is often a psychological component here too. Syncope is frightening. Presyncope is frightening. The fear of the next episode can become part of the condition. When patients learn what their warning signs are, what to do when symptoms rise, and how to train without overwhelming the system, that alone can create more stability.

Practical steps that can help patients feel safer

For many people with POTS, daily life becomes more manageable when they build rhythms and safeguards into their routine.

Carrying water consistently matters. Keeping rapid electrolyte support available matters. Learning to recognize warning signs before syncope matters. Sitting or lying down early when symptoms come on matters. Elevating the legs when needed can matter. Family members and friends may also need to know what an episode looks like and how to respond calmly.

That kind of support may sound basic, but it is powerful. Uncertainty amplifies fear. Preparedness reduces it.

A note for clinicians

If you are a chiropractor, physical therapist, coach, trainer, or student learning to work with more medically complex cases, POTS is a reminder to think bigger.

Not every dizzy patient has POTS. Not every fatigued patient has dysautonomia. But some do, and they may not present in the clean, textbook way you expect.

The lesson is not to overdiagnose. The lesson is to stay curious.

Take a thorough history. Learn the common clusters. Respect red flags. Encourage proper cardiology workup when needed. Notice overlap with hypermobility, migraines, GI dysfunction, autoimmune conditions, and post-viral changes. Understand that exercise may help, but only when properly dosed. Recognize that medications may stabilize symptoms in the short term while other interventions work toward broader function.

And perhaps most importantly, do not underestimate the value of collaboration. POTS patients often do best when providers stop competing for territory and start sharing perspective.

Final thoughts

POTS is complicated, but complicated does not mean hopeless.

For some patients, it has been present for years without a name. For others, it appears suddenly after illness or during a life stage they did not expect. For many, it affects far more than standing tolerance. It touches confidence, routines, relationships, food, training, work, and basic quality of life.

That is why this conversation matters.

POTS deserves more than dismissal. It deserves careful evaluation, practical support, collaborative care, and a willingness to look beyond the obvious. Some patients will need symptom management first. Some will need rehabilitation. Some will need nutritional and autonomic support. Some will need all of the above.

But many can improve.

Not all at once. Not always quickly. And not always through one intervention alone. But with the right awareness and the right care, many can regain function, resilience, and a sense of stability that once felt out of reach.