Printable tip sheet
If you are too tired to read through the whole article, here is the printable PDF.
The essentials, before you begin
What you’re testing for. POTS is a condition that affects the autonomic nervous system, which controls automatic body functions like heart rate and blood pressure, among others. When a person with POTS stands up, their heart beats much faster than normal leading to symptoms like dizziness or fatigue.
Who should consider testing for POTS? Testing for POTS can be meaningful if you have symptoms of orthostatic intolerance, particularly lightheadedness, palpitations, presyncope, generalized weakness, or blurred vision that occur with standing and improve with lying down.
The home standing test is a screening tool. It can raise suspicion but it cannot fully diagnose. POTS is a diagnosis that requires a clinician to rule out other causes (dehydration, medications, thyroid disease, adrenal issues, arrhythmias, anemia, structural heart disease, and more). But the test can give you and your clinician meaningful information and help start the conversation.
When not to do this test at home. If you have known cardiac disease, arrhythmias (abnormal cardiac rhythm, such as A-fib), a history of falls with injury, or you tend to lose consciousness rather than just feel lightheaded, do this test with your clinician rather than alone. If you are currently acutely ill, dehydrated, or newly on a medication that affects heart rate or blood pressure, wait for a more representative day.
What you need
A heart rate monitor of some kind. This can be:
A blood pressure cuff that measures heart rate in addition to blood pressure. This is beneficial to measure how your BP also changes with position change. You can buy this at any pharmacy or online.
A chest strap heart rate monitor
A fingertip pulse oximeter
A fitness tracker or smartwatch with continuous heart rate display
A wall you can lean against
A quiet room with no interruptions
About 20 minutes of free time
A notebook, phone note, or the printable protocol at the end of this post to record your numbers
If you can, get a family member or a friend to help you.
The test
Step 1. Lie flat and quiet for at least 10 minutes.
Turn your phone face-down. Don’t scroll, don’t read anything stimulating, don’t get up to check something. This is the resting phase, and the numbers depend on you actually being at rest. Bathroom before you start.
Step 2. Take your resting heart rate.
At the end of the 10 minutes, still lying down, record your heart rate. Take it again a minute later and average the two. Write both numbers down.
Step 3. Stand up and lean lightly against a wall.
Shoulders and buttocks touching the wall, heels 6-8 inches out from the baseboard. This is a supported stand not rigid attention.
Step 4. Record your heart rate at 1, 3, 5, and 10 minutes of standing.
Stay against the wall the entire time. Don’t shift weight, don’t cross your ankles, don’t fidget as those small movements activate the calf muscles and can artificially lower your heart rate.
Step 5. Record your symptoms as they happen.
Lightheadedness, palpitations, nausea, brain fog, tingling, visual changes, ringing in the ears, feeling faint, warmth in the face, cold hands, tremor.
Step 6. Sit or lie down
Record how you feel after the test and note how quickly symptoms resolve.
Interpreting your numbers
POTS is defined by a specific pattern. When you stand, your heart rate rises by at least 30 beats per minute above your lying-down rate within 10 minutes of standing (or 40 bpm if you are under 20) without a significant drop in blood pressure, and with symptoms.
A more transient spike in the first minute or two that then settles back down is common and not specific for POTS.
If your heart rate rises but you are also experiencing a significant drop in blood pressure, that points toward orthostatic hypotension rather than POTS, a different condition with different management.
Symptoms matter as much as numbers. Some patients have a clear POTS heart rate pattern with modest symptoms. Others have significant symptoms with borderline numbers. Both are worth taking to a clinician. As I said earlier, this test is meant to be a conversation starter.
What to do with your results
If your test suggests POTS. Bring the numbers to your clinician. Ask them to look at the pattern with you. Depending on your other conditions, the right next referral may be to cardiology, to a neurologist with autonomic expertise, or to an internist familiar with dysautonomia. Your physician may also give you direction on beneficial lifestyle changes. Be aware that not every clinician is comfortable evaluating for POTS, and even less are comfortable treating POTS.
If your test is normal but you have significant symptoms. A negative home test does not rule out POTS. Symptoms can fluctuate day to day; your hydration status, sleep, hormones, and stress load all affect the numbers. If your symptoms are real and consistent, the test being negative on one occasion should not close the door. You can repeat the test on another day, Or you may need a formal tilt table test in an autonomic lab that is more sensitive than the home version.
If you have MS, hEDS, small fiber neuropathy, or a rare neuroimmune condition. Even a mild positive result is worth raising. Dysautonomia is a well-documented comorbidity of these conditions, and may be a missing piece contributing fatigue, brain fog, or exercise intolerance.
If your test is unremarkable and your symptoms are mild. That’s useful information too. It doesn’t rule out other forms of autonomic dysfunction, but it makes classical POTS less likely as the explanation.
In your corner,
Dr. Freeman