POTS
Your heart races when you stand, with dizziness, fatigue, brain fog or nausea that ease when you lie down. Often starts after a virus, surgery or pregnancy. Most people improve with a steady plan.
The POTS ladder
Evidence is mostly small studies, but the basics help most people. Build up over months, not days.
- Step 1 · Self-careFluids and salt2–3 litres of fluid a day, plus extra salt if your doctor says it’s suitable. Two glasses of water before getting up helps mornings.
- Works
- Small studies only, but helps many people and is low risk
- Cost
- About $0–30 a month (electrolyte tablets are optional)
- How long
- Days to weeks to notice
- Watch for
- Extra salt isn’t suitable with high blood pressure, or heart or kidney disease.
Your water bottle is now a key accessory. Treat it accordingly.
- Step 2 · PharmacyCompression garmentsWaist-high medical-grade stockings or an abdominal binder, to stop blood pooling in the legs and belly.
- Works
- Small studies: less heart-rate rise and fewer symptoms on standing
- Cost
- About $100–250 for waist-high stockings; binders about $30–80
- How long
- Works while you wear it
- Watch for
- Knee-high socks do little. Hot and fiddly in summer.
Not high fashion. Often highly effective.
- Step 3 · Allied healthGraded exercise with an exercise physiologist or physioStart lying or sitting (recumbent bike, rowing, swimming) and build up slowly.
- Works
- About 7 in 10 who finished a 3-month program no longer met POTS criteria (no control group; many dropped out)
- Cost
- About $90–130 a session; Medicare rebates with a GP care plan
- How long
- 3 months or more
- Watch for
- Symptoms may worsen at first, then improve. Lots of bed rest makes POTS worse.
Start horizontal. Upright comes later, and it’s worth the wait.
- Step 4 · PrescriptionLow-dose propranolol or ivabradineSlows the heart rate on standing.
- Works
- Small trials: both lower standing heart rate; helps some, especially with a very fast heart rate
- Cost
- Propranolol: under the $25 PBS co-payment, about $10–20. Ivabradine: about $40–80 a month private
- How long
- Days to weeks
- Watch for
- Tiredness, low blood pressure. Propranolol: not with asthma. Ivabradine: not in pregnancy; brief visual flashes.
Low dose is the point. More isn’t better here.
- Step 5 · PrescriptionFludrocortisone, midodrine or pyridostigmineBoost blood volume or tighten blood vessels, chosen with a specialist when other steps aren’t enough.
- Works
- Small, short trials only; helps some people. None is specifically approved for POTS in Australia
- Cost
- About $15–60 a month, depending on the medicine and PBS eligibility
- How long
- Weeks to judge
- Watch for
- Fludrocortisone: low potassium, high blood pressure. Midodrine: scalp tingling, high blood pressure lying down. Pyridostigmine: tummy cramps.
Medicines help the basics. They don’t replace them.
- Step 6 · SpecialistCardiologist or autonomic clinicTo confirm the diagnosis, check for other causes, and fine-tune treatment.
- Works
- No trials; most useful when the diagnosis is unclear or symptoms are severe
- Cost
- About $150–300 for a first visit, with a Medicare rebate on referral; tests extra
- How long
- Waits can be months
- Watch for
- Tilt-table and heart tests may be needed.
Bring your lying and standing heart-rate readings. Numbers beat adjectives.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Bed restMakes deconditioning, and so POTS, worse. Lying low feels right but works against you.
- Regular IV saline dripsShort-lived relief, with real risks of infection and clots from long-term drips. Not a routine treatment.
- IVIG (immunoglobulin) infusionsA trial found no clear benefit over a dummy treatment infusion, and they are expensive and scarce.
- Restrictive diets without a diagnosisGluten-free or elimination diets help only if you have coeliac disease or a real food allergy.
- Antibody tests sold onlineResearch tools, not diagnostic tests. They don’t change treatment.
What you can do
- Get up slowly: sit on the edge of the bed for a minute first.
- If symptoms start, cross your legs, squeeze your thighs and buttocks, or sit or lie down.
- Avoid hot showers (or sit to wash), hot weather, big carbohydrate meals and alcohol.
- Keep a regular sleep routine, and pace your activities on bad days.
See your GP if
- You get dizzy or your heart races every time you stand
- Symptoms stop you working, studying or exercising
- You take medicines that may worsen symptoms, such as some blood pressure tablets or antidepressants
Call 000 if you faint during exercise, faint with chest pain or palpitations, or have chest pain or trouble breathing.
Common questions
How is POTS diagnosed?
By a heart rate rise of at least 30 beats per minute (40 in teenagers) within 10 minutes of standing, without a drop in blood pressure, along with typical symptoms.
What helps POTS symptoms?
Drinking 2 to 3 litres of fluid a day, extra salt if suitable, compression garments and gradual exercise that starts lying or sitting. Lying in bed a lot makes it worse.
Does POTS go away?
Most people improve with treatment, though it can take months of gradual exercise.
Is there medicine for POTS?
Medicines such as low-dose propranolol, ivabradine, fludrocortisone, midodrine or pyridostigmine are sometimes used when other measures aren’t enough. None is specifically approved for POTS in Australia.
What causes POTS?
Often it starts after a viral illness (including COVID-19), pregnancy, surgery or a period of bed rest. It’s most common in women aged 15 to 50 and is linked with joint hypermobility in some people. Often no single cause is found.
What are the symptoms of POTS?
Dizziness, a racing heart, shakiness and tiredness on standing, which ease when lying down. Brain fog, headaches, nausea, feeling faint and poor exercise tolerance are common too.
Is POTS a heart condition?
Not really. The heart itself is healthy; the problem is how the nervous system controls blood flow and heart rate when you stand. The fast heartbeat is the body’s response to blood pooling in the legs.
Helpful resources
- PoTS UKPatient charity with evidence-based information and downloadable leaflets. Free, UK.
- Dysautonomia International: For educatorsPrintable information to help schools understand POTS and plan support. Free.
Evidence and more information
- Healthdirect: POTS
- PoTS UK: PoTS on a page (GP guide)
- Metro North Health: POTS management for GPs
- George et al: International POTS registry exercise program (Heart Rhythm 2016)
maladywise.com/pots/