Postural Orthostatic Tachycardia Syndrome: Mechanisms and New Therapies

Annu Rev Med. 2020 Jan 27;71:235-248. doi: 10.1146/annurev-med-041818-011630. Epub 2019 Aug 14.


Postural orthostatic tachycardia syndrome (POTS) is a clinically heterogeneous disorder with multiple contributing pathophysiologic mechanisms manifesting as symptoms of orthostatic intolerance in the setting of orthostatic tachycardia (increase in heart rate by at least 30 beats per minute upon assuming an upright position) without orthostatic hypotension. The three major pathophysiologic mechanisms include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state. Patients often will exhibit overlapping characteristics from more than one of these mechanisms. The approach to the treatment of POTS centers on treating the underlying pathophysiologic mechanism. Stockings, abdominal binders, and vasoconstrictors are used to enhance venous return in partial neuropathic POTS. Exercise and volume expansion are the main treatment strategies for hypo-volemic POTS. For hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors is important. Attempts should be made to discern which pathophysiologic mechanism(s) may be afflicting patients so that treatment regimens can be individualized.

Keywords: POTS; autonomic dysfunction; orthostatic intolerance; pathophysiology; postural orthostatic tachycardia syndrome; tachycardia.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Cardiovascular Agents / therapeutic use*
  • Clonidine / therapeutic use
  • Combined Modality Therapy
  • Female
  • Humans
  • Ivabradine / therapeutic use*
  • Male
  • Methyldopa / therapeutic use
  • Postural Orthostatic Tachycardia Syndrome / diagnosis*
  • Postural Orthostatic Tachycardia Syndrome / mortality
  • Postural Orthostatic Tachycardia Syndrome / psychology
  • Postural Orthostatic Tachycardia Syndrome / therapy*
  • Quality of Life*
  • Risk Assessment
  • Severity of Illness Index
  • Survival Analysis
  • Treatment Outcome


  • Adrenergic beta-Antagonists
  • Cardiovascular Agents
  • Ivabradine
  • Methyldopa
  • Clonidine