Postural Orthostatic Tachycardia Syndrome (POTS)

Written by Lauren Glucina, Naturopath at Urban Herbalist.

Orthostatic (postural) hypotension is an excessive fall in blood pressure (BP) when moving to an upright position, be it sitting or standing. This condition is due to abnormal BP regulation and is known as a dysautonomia – a disorder of the autonomic nervous system.

Postural orthostatic tachycardia syndrome (POTS) is a type of orthostatic intolerance that tends to occur in younger patients aged 15-25 years, predominantly affecting females (six times more than males), and is charcterised by a rapid increase in heart rate on standing or sitting upright, though with little or no fall in Blood pressure [1].

Normally, gravity will naturally cause blood to pool in the legs and torso when we stand. This causes a transient decrease in the amount of venous blood flow back to the heart, in turn reducing cardiac output and lowering BP.

In response, automatic reflexes kick in to rapidly return BP to normal – by narrowing blood vessels and increasing heart rate. When this happens, the changes in both BP and heart rate on standing are barely noticeable, so much so its a bit of a non-event.

Further – when we remain upright, certain hormones are secreted that promote sodium and water retention, increasing blood volume.

In someone with POTS, this regulatory process is abnormal, and may cause a raft of debilitating symptoms.

POTS however is not a life-threatening condition and is expected to naturally improve over time, though may follow a pattern of remitting and relapsing.

Symptoms may include -

Extreme tachycardia
Heart palpitations
Extreme fatigue
Light headedness, dizziness
Loss of sweating the extremities
Blood pooling with decolourisation of the feet (a red/blue/purple hue)
Decreased tolerance to exercise
Brain fog, difficulty thinking


The diagnostic criteria for POTS is an increase in heart rate of 30 beats per minute (bpm) or more, or over 120 bpm, within the first 10 minutes of standing, in the absence of orthostatic hypotension (a fall in BP).

Diagnosis is typically via a Cardiologist or Neurologist, and may involve an ECG or Holter monitor test.

Further blood and urine testing can help identify what subtype a patient may have – that is, either Hypovolemic, Neuropathic or Hyperadrenergic POTS. These phenotypes may overlap.

Hypovolemic POTS patients have low blood volume due to the abnormal activation of the renin-angiotensin-aldosterone system. Symptoms may include weakness, chronic fatigue and decreased tolerance to exercise [2].

Neuropathic POTS is associated with damage to small fiber nerves and may present with a purple discolouration of the feet/lower legs as the blood pools on standing [2].

Hyperadrenergic POTS is due to excess sympathetic response with elevations of the stress hormone noradrenaline. These patients will present with hypertension on standing, and may also have lightheadedness, faintness, palpitations, shortness of breath, syncope, tremours, headaches, fatigue, nausea and vomiting [2].

The post-viral fatigue link

POTS can be triggered by viral or bacterial infection, surgery and other health events, it is also suspected there is an autoimmune element.

We have certainly noticed an increase in people presenting with POTS since the outbreak of COVID-19 started.

A recent review paper asserted that a significant percentage of people (25-50%) with long-COVID develop POTS [3] – often, quite some time after exposure to the virus [4].

There is no clear understanding yet as to why this occurs, however it could be due to autoantibody production against autonomic nerve fibres, toxicity due to the virus itself, or sympathetic nervous system stimulation secondary to the infection [4].

Chronic fatigue syndrome

Symptoms found in POTS are similar to those with chronic fatigue syndrome, and they often co-occur.

Both conditions are characterised by dramatically reduced blood flows to the brain, and likely, other organs [3].

Dietary and lifestyle treatment

There are a variety of dietary and lifestyle interventions that can help relieve symptoms ­

An increase in salt and water intake (salt supplements however should be used with caution in Hyperadrenergic POTS)
Caffeine avoidance, particularly in Hyperadrenergic POTS
Alcohol avoidance
Consuming smaller, more frequent meals, high in fibre to support healthy blood glucose
Getting quality sleep
Raising the head of your bed
Regular, graded exercise (swimming is fantastic)

Perhaps the most helpful of the above, is the first point regarding salt and hydration.

The Cleveland Clinic recommend POTS patients consume 3,000-10,000mg of sodium daily [5] – for context, the average intake for adults is 460-920mg per day.

Additional salt may come in the form of over-salting foods, consuming salty snacks or taking salt tablets. Salt helps POTS patients retain water in the blood vessels, in turn elevating BP to normal.

Hydration meanwhile is also key, for the same reason. Aim to drink about 2-2.5 litres daily.

High salt snacks include salted nuts, V8 vegetable juice, salted popcorn and jerky.

Herbal, nutritional treatment

B-group vitamins are essential for the health of the nervous system, while deficiencies of B1 and B12 in particular have been found in those with POTS [2]. A quality B-complex can help optimise nutrient status and have the added benefit of providing energy.

Magnesium can help slow a rapid heart rate. 350Mg daily of a magnesium citrate, glycinate or chelate, avoiding magnesium oxide as this is poorly absorbed and increases osmolarity in the bowel.

CoQ10 is a powerful antioxidant that protects mitochondria and supports the cardiovascular system. CoQ10, like magnesium, may also help alleviate fatigue.

Nicotinamide adenine dinucleotide (NADH) helps your body make energy. A randomised, double-blind, placebo-controlled study found CoQ10 in conjunction with NADH reduced cognitive fatigue and improved quality of life in those with chronic fatigue syndrome [6].

Alpha lipoic acid (ALA) is another antioxidant that aids in energy production, though with an affinity for the nerves, so may be helpful for those with Neuropathic POTS. ALA has been well-studied for use in Diabetic neuropathy, helping provide relief from pain, numbness, itching and burning.

Licorice root is an adaptogen herb well known for its ability to support adrenal health, and has the potential to increase blood pressure. To this point, it is contraindicated in those with hypertension and should always be prescribed by a qualified practitioner for safe use.

Ziziphus, Passionflower, California poppy, Lavender. Since poor sleep quality can exacerbate POTS symptoms, herbs that help relax the nervous system and promote a restful night's sleep can be helpful.

Pharmacological treatment

Medications may be prescribed where nutritional and lifestyle interventions are not enough, such as a beta blockers, Midodrine or Fludrocortisone.

Factors that worsen POTS symptoms include ­

Being in warm environments (this includes a hot shower)
Standing for long periods
Strenuous exercise
Acute illness (cold, infection)
Being on your period

How we can help

If you've been diagnosed with POTS and would like to try some of the discussed natural interventions, come in for a chat or book a consultation with us. Be sure to disclose any medications so we can carefully check for interactions and contraindications.

Lauren Glucina, Naturopath at Urban Herbalist.