Published peer-reviewed research shows that Cognitive FX treatment leads to meaningful symptom reduction in post-concussion symptoms for 77% of study participants. Cognitive FX is the only PCS clinic with third-party validated treatment outcomes.
READ FULL STUDY
If you've been searching for answers about your racing heart, dizziness, and fatigue, you're probably wondering: how do doctors actually diagnose POTS? The short answer is that Postural Orthostatic Tachycardia Syndrome is diagnosed when your heart rate increases by 30 beats per minute or more (40 bpm for adolescents) within 10 minutes of standing, without a significant drop in blood pressure. But the reality of getting that diagnosis is far more complicated than a single test.
For most people with POTS, the path to diagnosis is long, frustrating, and often emotionally exhausting. Research shows the average patient waits nearly 5 years and sees 7 different doctors before finally getting answers. Many are told their symptoms are "just anxiety" before anyone thinks to check their heart rate while standing.
This guide walks you through everything you need to know about the POTS diagnostic process, from the official criteria to what the tests actually feel like, and what to do if doctors aren't taking your symptoms seriously.
Before diving into the tests themselves, it's important to understand why so many people struggle to get diagnosed. The statistics paint a troubling picture.
A landmark 2019 study surveying nearly 5,000 POTS patients found that the average time from symptom onset to diagnosis was 4.9 years. Other research puts this figure even higher, with some studies reporting delays of nearly 6 years on average.
During this time, patients see an average of 7 physicians before someone finally identifies POTS. About one in five patients consult more than 10 doctors before getting answers, and 34% ultimately have to suggest the diagnosis themselves after doing their own research.
Perhaps most concerning: 69% of POTS patients are diagnosed with an anxiety disorder before receiving their POTS diagnosis, and 59% report being told their symptoms are "all in your head."
Research reveals a significant gender disparity in POTS diagnosis. Women wait an average of 5 years for diagnosis compared to 3 years for men. Given that 80-85% of POTS patients are female, this disparity affects the vast majority of people with the condition.
Dr. Satish Raj, a leading POTS researcher at the University of Calgary, has spoken candidly about this issue: "There's an element of dismissiveness and misogyny in the room. The POTS demographic is women who, for the most part, look pretty well... I think that gets dismissed as anxiety a lot."
The main barrier to faster diagnosis is lack of physician awareness. According to a 2019 NIH Expert Consensus statement, meaningful discussions of autonomic disorders including POTS "are not included in most medical school curricula, or even in residency/fellowship training." This means many doctors simply don't know what POTS is or how to test for it.
The irony is that POTS isn't difficult to diagnose once a physician knows what to look for. As Dr. Peng-Sheng Chen at Cedars-Sinai explains, "POTS is easy to spot and diagnose, if medical professionals know what to look for."
What POTS patients experience before getting answers
How often POTS patients are told it's psychological
"Research shows POTS patients have no increased prevalence of anxiety disorders compared to the general population." — Raj et al.
Women wait significantly longer for a POTS diagnosis
Breakdown by specialist type
Heart rate increase within 10 minutes of standing
Or heart rate exceeding 120 BPM within 10 minutes of standing
Higher threshold due to normal adolescent heart rate variability
Important: Diagnosis also requires ruling out orthostatic hypotension (blood pressure drop ≥20/10 mmHg) and symptoms present for at least 3-6 months.
New POTS diagnoses before vs. after the pandemic
Source: University of Toledo Research, 2025 | ~30% of severely symptomatic Long COVID patients develop POTS
Common conditions that occur alongside POTS
Ehlers-Danlos Syndrome and POTS frequently co-occur
Evidence of small fiber nerve involvement
Mast Cell Activation Syndrome overlap
Understanding the diagnostic criteria can help you advocate for proper testing. Here's what medical professionals look for.
For adults age 20 and older, POTS is diagnosed when heart rate increases by 30 beats per minute or more within 10 minutes of standing upright. Alternatively, if heart rate exceeds 120 bpm during that timeframe, the criteria are also met.
For adolescents between ages 12 and 19, the threshold is higher: a heart rate increase of 40 bpm or more within 10 minutes of standing. This higher threshold exists because healthy teenagers naturally experience more heart rate variability when changing positions.
A POTS diagnosis requires ruling out orthostatic hypotension, which is a significant drop in blood pressure upon standing (20 mmHg systolic or 10 mmHg diastolic within 3 minutes). If blood pressure drops substantially when you stand, that's a different condition that requires different treatment.
The 2020 Canadian Cardiovascular Society guidelines also recommend a minimum resting heart rate of 60 bpm before testing to prevent false positive diagnoses.
Symptoms must be present for at least 3 to 6 months to be considered chronic. This helps distinguish POTS from temporary conditions like dehydration or acute illness that can cause similar symptoms short-term.
While the diagnostic criteria focus on heart rate, doctors should consider POTS testing when patients report symptoms like lightheadedness or dizziness when standing, heart palpitations or racing heart, fatigue that worsens with activity, brain fog or difficulty concentrating, exercise intolerance, nausea, headaches, shakiness or tremors, and chest discomfort. Symptoms characteristically improve when lying down and worsen when upright.
The tilt table test is considered the gold standard for POTS diagnosis. Here's what to expect if your doctor orders one.
You'll need to fast for 2 to 4 hours before the test, meaning no food or drinks. Avoid caffeine entirely on test day. Your doctor may ask you to temporarily stop certain medications that could affect the results, including beta-blockers, calcium channel blockers, and some antidepressants. Always discuss medication changes with your prescribing physician first.
Plan to have someone drive you home afterward, as you may feel tired or lightheaded.
The test takes place in a cardiology or autonomic testing lab. Here's the typical sequence.
You'll lie flat on a special motorized table with a footrest and safety straps around your torso and legs. Medical staff will attach ECG electrodes to monitor your heart rhythm, a blood pressure cuff on your arm (and sometimes a continuous finger blood pressure monitor), and a pulse oximeter on your finger.
You'll rest in the flat position for 5 to 20 minutes while baseline measurements are recorded. Then the table tilts to an angle between 60 and 80 degrees (most commonly 70 degrees) over about 15 seconds. You'll remain in this near-upright position, supported by the footrest and straps, for 10 to 45 minutes.
Throughout the test, staff continuously monitor your heart rate, blood pressure, and symptoms. You'll be asked to stay as still as possible and avoid tensing your leg or buttock muscles, as this can affect results.
Most people with POTS will start experiencing their typical symptoms during the tilt portion: racing heart, dizziness, lightheadedness, sweating, nausea, or that familiar "I need to sit down" feeling. Some patients faint during the test, which is actually useful diagnostic information. If this happens, the table is immediately returned to horizontal.
The test isn't painful, but it can be uncomfortable, especially if you're used to avoiding standing for long periods. Many patients describe it as "like standing in line at the DMV, but lying down."
The table returns to horizontal, and you'll rest for 15 to 20 minutes while your vitals normalize. Staff may discuss preliminary results with you immediately, though formal results typically come within a few days.
Plan for the rest of the day to be low-key. Many people feel tired or "off" for several hours after the test.
While the tilt table test is considered the gold standard, it's not perfect. Studies show sensitivity around 93% at 10 minutes, meaning it catches most POTS cases. However, specificity at the standard 30 bpm threshold is only about 40%, meaning some people without POTS may test positive.
This is why diagnosis shouldn't rely solely on heart rate numbers. The presence of characteristic symptoms during the test is equally important.
Not everyone has access to a tilt table test, and some doctors prefer simpler in-office assessments. Here are the alternatives.
This test can be performed in any doctor's office with basic equipment. You lie flat for 10 minutes while baseline heart rate and blood pressure are recorded. Then you stand as still as possible for 10 minutes while measurements are taken at 2, 5, and 10 minute intervals.
The key difference from the tilt table test is that active standing involves your "skeletal muscle pump," where leg muscle contractions help push blood back toward your heart. This can reduce the heart rate response compared to passive tilting.
Research suggests fewer patients meet POTS criteria on active standing (74%) compared to tilt table testing (98%). Some researchers recommend using a lower threshold of 27 bpm for the active standing test to account for this difference.
Originally developed by NASA to study astronauts with orthostatic intolerance, this test requires minimal equipment and can even be performed at home for preliminary screening.
The protocol involves lying flat for 10 minutes to establish baseline measurements, then standing with your shoulder blades against a wall and your heels 6 to 8 inches away from the wall. You maintain this relaxed leaning position for 10 minutes while heart rate and blood pressure are measured each minute.
The wall support provides a middle ground between passive tilt table testing and active standing. It's particularly useful for patients who have difficulty standing unsupported for extended periods.
While a formal diagnosis requires medical evaluation, you can do a preliminary assessment at home using the active standing test or NASA lean test protocols. You'll need a reliable blood pressure monitor that also displays heart rate, or a pulse oximeter and separate blood pressure cuff.
However, there are important caveats. Home testing can provide useful information to bring to your doctor, but shouldn't replace professional evaluation. Results can vary based on time of day, hydration status, recent meals, and other factors. A single positive home test doesn't confirm POTS, and a negative test doesn't rule it out.
If your home testing suggests POTS, bring your documented measurements to your doctor as evidence to support formal testing.
Diagnosing POTS often involves ruling out other conditions and identifying potential underlying causes. Here are additional tests your doctor may order.
Standard labs help rule out conditions that can cause similar symptoms. These typically include complete blood count to check for anemia, thyroid function tests to rule out hyperthyroidism, a basic or comprehensive metabolic panel for electrolyte abnormalities, iron studies, cortisol levels for adrenal function, glucose and HbA1c for diabetes, celiac panel, ANA and inflammatory markers for autoimmune conditions, and vitamin B12.
For patients suspected of having hyperadrenergic POTS, doctors may order plasma catecholamines. Blood is drawn while lying down, then again after standing for 10 to 20 minutes. Standing norepinephrine levels above 600 pg/mL suggest hyperadrenergic POTS.
A 24-hour urine collection for catecholamines helps rule out pheochromocytoma, a rare adrenal tumor. Low urinary sodium in the collection may indicate the hypovolemic POTS subtype.
A comprehensive autonomic evaluation may include the Valsalva maneuver, where you blow into a tube at a set pressure while heart rate and blood pressure are monitored. There's also heart rate variability testing during deep breathing, which assesses parasympathetic function, and the isometric handgrip test for additional autonomic assessment.
The Quantitative Sudomotor Axon Reflex Test measures sweat gland function controlled by small nerve fibers. Electrodes placed on your forearm and legs deliver mild electrical stimulation while sweat output is measured. About 56% of POTS patients have abnormal results on this test, often showing reduced sweating in the legs and feet. This helps identify neuropathic POTS.
An echocardiogram uses ultrasound to visualize your heart, ruling out structural abnormalities or valve problems like mitral valve prolapse. A 24-hour Holter monitor continuously records your heart rhythm, helping identify arrhythmias and documenting heart rate patterns during symptomatic episodes.
POTS rarely exists in isolation. Your doctor should consider screening for Ehlers-Danlos Syndrome (EDS) if you have joint hypermobility, stretchy skin, or easy bruising, since 80% of EDS patients have POTS. Mast Cell Activation Syndrome (MCAS) testing is warranted if you have flushing, hives, or unexplained allergic-type reactions, as 42% of POTS patients have MCAS symptoms. Small fiber neuropathy evaluation through skin biopsy should be considered if you have burning pain, numbness, or tingling in your extremities, given that 50% of POTS patients show evidence of small fiber nerve damage.
Finding the right specialist can significantly impact your diagnostic journey.
Research on POTS patients shows that cardiologists diagnose 41% of cases, neurologists diagnose 19%, cardiac electrophysiologists diagnose 15%, and family physicians diagnose 8%.
Cardiologists are often the first specialists patients see because of heart-related symptoms like palpitations and racing heart. They can order tilt table tests, echocardiograms, and Holter monitors. However, not all cardiologists are familiar with POTS.
Cardiac electrophysiologists subspecialize in heart rhythm disorders and traditionally have been considered "POTS experts." They developed the tilt table test and often have the most experience with autonomic conditions. However, there are only about 3,000 electrophysiologists in the U.S. for an estimated 1 to 3 million POTS patients.
Neurologists may be particularly helpful if your symptoms include brain fog, headaches, or suspected small fiber neuropathy. They can perform QSART testing and order skin biopsies.
Autonomic specialists are the ideal choice for complex cases, but they're rare. Dedicated autonomic clinics exist at major centers like Vanderbilt, Mayo Clinic, Cleveland Clinic, and Johns Hopkins. Wait times can exceed a year.
Yes. Any physician can diagnose POTS if you meet the criteria. A primary care doctor can perform an active standing test in the office, order basic blood work, and make the diagnosis if results are clear.
The challenge is finding a primary care provider who knows what POTS is and takes the symptoms seriously. If your doctor dismisses your concerns, consider seeking a second opinion or requesting a referral to a specialist.
Dysautonomia International maintains a physician directory at dysautonomiainternational.org. Standing Up to POTS at standinguptopots.org also offers resources. Local POTS support groups on Facebook or Reddit often share recommendations. When calling to schedule, ask directly: "Does this doctor have experience diagnosing and treating POTS?"
One of the most painful aspects of the POTS diagnostic journey is encountering medical professionals who dismiss your symptoms. Here's how to advocate for yourself.
POTS and anxiety share overlapping symptoms like racing heart, sweating, and feeling faint. This is why so many POTS patients are initially misdiagnosed with anxiety disorders. But there are key differences.
With POTS, symptoms are triggered by position changes and improve when lying down. Anxiety symptoms can occur in any position and aren't reliably relieved by lying flat. POTS symptoms have measurable physiological markers, specifically the heart rate increase upon standing. Anxiety-related heart rate increases don't follow this predictable positional pattern.
As one patient put it: "A POTS episode is pretty easy to tell from anxiety. There's little to no psychological anxiety, panic, or worry. You just feel out of it and very sick. It's all physical."
If you suspect POTS, try these approaches. You might say "I've noticed my heart rate increases significantly when I stand up. I've been tracking it at home. Can we do a standing test to check for POTS?" Or "I know my symptoms might look like anxiety, but they only happen when I'm upright and get better when I lie down. That pattern suggests something autonomic might be going on." Or "I'd like to try a 10-minute standing test before we attribute this to anxiety. If my heart rate increases by 30 beats per minute, that would meet the criteria for POTS."
Consider finding a new provider if your doctor refuses to perform basic testing, if you're told it's "just anxiety" without any objective measurements, if symptoms are dismissed because "your labs are normal," or if you've been given psychiatric medication that hasn't helped and no one has reconsidered the diagnosis.
Bring evidence to appointments. Keep a symptom diary noting when symptoms occur, what triggers them, and what helps. Record home heart rate and blood pressure measurements in different positions. Track heart rate patterns using a fitness tracker or smartwatch. Note how symptoms impact your daily function, like whether you have difficulty working, exercising, or standing in line.
Use these evidence-based questions to help get the testing, diagnosis, or referral you need. Many patients wait years because they don't know what to ask.
Start here if you haven't been tested for POTS
Why it works: This describes the active standing test without medical jargon. Any doctor can do this in-office with basic equipment.
Why it works: Bringing documented evidence shows you've done your homework and gives the doctor concrete data to work with.
Why it works: Emphasizing the positional pattern is key. This distinguishes your symptoms from anxiety or other conditions.
69% of POTS patients are first misdiagnosed with anxiety
Why it works: You're not dismissing their assessment, just requesting objective testing first. A 10-minute standing test can provide clarity.
Why it works: This gives the doctor a measurable threshold to test against. A 30+ bpm increase is the diagnostic criteria for adults.
Why it works: If you've tried anxiety treatment without improvement, this is important diagnostic information that warrants further investigation.
Cardiologists diagnose 41% of POTS cases
Why it works: Specifying "experience with dysautonomia" helps you get a specialist who actually knows how to diagnose and treat POTS.
Why it works: Directly requesting the specific test shows you know what you need. Tilt table tests are typically done by cardiologists or in autonomic labs.
Why it works: This is respectful but direct. It acknowledges their expertise while opening the door to see someone more specialized.
Important follow-up questions to understand your results
Why it works: Get the actual numbers. Adults need 30+ bpm increase; adolescents need 40+ bpm. You deserve to know your specific results.
Why it works: 80% of EDS patients have POTS, and 42% of POTS patients have MCAS. Identifying comorbidities improves treatment outcomes.
Why it works: Having POTS in your official medical record prevents future providers from starting the diagnostic process over again.
Bring DataShow heart rate logs from a smartwatch or blood pressure monitor. Numbers are harder to dismiss than descriptions.
Write It DownBring your questions printed out. It's easy to forget in the moment, and it shows you're prepared.
Bring SupportA family member or friend can advocate for you, take notes, and help you remember what was said.
Stay FocusedLead with your most concerning symptom and the positional pattern. Don't overwhelm with every symptom at once.
Remember: You're not being difficult by asking for testing.
You're advocating for answers you deserve.
The COVID-19 pandemic has brought new attention to POTS, as many people developed the condition after infection.
Research suggests approximately 30% of severely symptomatic long COVID patients meet the criteria for POTS. Some studies report even higher rates: one found 79% of long COVID patients had POTS.
A 2025 study from the University of Toledo documented the surge in diagnoses: before the pandemic, their clinic saw an average of 4.21 new POTS cases per month. After COVID emerged, that jumped to 22.66 new cases monthly, representing more than a five-fold increase.
Post-COVID POTS patients often report higher rates of brain fog, internal tremors, and tinnitus compared to other POTS patients. There's significant overlap with mast cell activation syndrome and ME/CFS. Symptoms may appear during acute infection or emerge months later.
The American Autonomic Society recommends standard POTS criteria plus orthostatic symptoms present at least 12 weeks after COVID-19 infection. The diagnostic tests are the same as for any POTS patient.
Researchers increasingly recognize a "trifecta" of conditions that frequently occur together: POTS, Ehlers-Danlos Syndrome, and Mast Cell Activation Syndrome.
About 80% of people with hypermobile EDS also have POTS. The connection likely involves the weak connective tissue in EDS affecting blood vessel function and blood flow regulation.
Similarly, 42% of POTS patients show evidence of mast cell activation. These overlapping conditions can complicate diagnosis, but identifying all three when present leads to better treatment outcomes.
If you have POTS, your doctor should assess for joint hypermobility using the Beighton score, a 9-point system that evaluates flexibility at various joints. High scores suggest possible hypermobile EDS and may prompt genetic evaluation.
You can perform preliminary testing at home using the active standing test or NASA lean test protocols, which may provide useful information to share with your doctor. However, a formal POTS diagnosis requires evaluation by a healthcare provider to rule out other conditions and confirm the findings. Home testing is best used as a screening tool or to document your symptoms for medical appointments.
Unfortunately, research shows the average POTS patient waits 4 to 6 years and sees 7 different doctors before receiving a diagnosis. This delay is largely due to lack of physician awareness about the condition. Patients who educate themselves about POTS and advocate for testing often receive faster diagnoses. About 34% of patients suggest the diagnosis to their doctor themselves.
Yes. While some POTS patients do faint, many never lose consciousness. The hallmark of POTS is the heart rate increase upon standing, not fainting. Common symptoms without fainting include dizziness, lightheadedness, palpitations, fatigue, brain fog, and the feeling that you might faint even if you don't actually pass out.
POTS and anxiety can cause similar symptoms like racing heart and sweating, which is why misdiagnosis is common. The key difference is that POTS symptoms are triggered by standing upright and improve when lying down. This positional pattern doesn't occur with anxiety. Additionally, POTS produces a measurable heart rate increase of 30+ bpm upon standing, which can be objectively documented.
No. While the tilt table test is considered the gold standard, POTS can also be diagnosed using the active standing test or NASA lean test. These simpler tests can be performed in a regular doctor's office without specialized equipment. The key requirement is measuring heart rate and blood pressure while lying down and again after standing for up to 10 minutes.
Cardiologists and cardiac electrophysiologists diagnose the majority of POTS cases. Neurologists with autonomic expertise are also good options, especially if you have symptoms like brain fog or suspected neuropathy. However, any knowledgeable physician, including primary care doctors, can diagnose POTS. The most important factor is finding a provider who takes your symptoms seriously and knows how to test for the condition.
Getting a POTS diagnosis can feel like an uphill battle, but understanding the process puts you in a better position to advocate for yourself. If you suspect you have POTS, start by tracking your symptoms and heart rate patterns at home. Bring this documentation to your doctor and specifically request testing for POTS.
Remember: you're not imagining your symptoms, and you deserve a thorough evaluation. The average diagnostic delay of nearly 5 years isn't acceptable, and you don't have to accept being dismissed.
If you've been struggling with unexplained symptoms that worsen when you stand, there are answers available. Sometimes finding them just requires persistence and the right medical team willing to listen.
Sources:
Dr. Lynn Gaufin graduated from the University of Utah and then attended medical school at Cornell University in New York City. After medical school he join the Army and was a surgeon in the military before finishing his Neurological Residency at University of California Los Angeles. Dr. Gaufin specializes in cervical and lumbar spine surgery, brain tumors, brain hemorrhages, and treatment of traumatic brain injuries. Dr. Gaufin is one of the emergency trauma neurosurgeons on call at Utah Valley Hospital. Before he began his practice in Utah he saw a significant amount of traumatic brain injuries during his career in the Army and his residency in Los Angeles. As a surgeon who treats individuals who suffer from mild to severe traumatic brain injuries he recognized a problem in the post operative rehabilitation. Individuals who suffered severe trauma would be admitted into speciality facilities where they would receive months of care. But patients who had a more mild trauma would be released and would largely be on their own when it came to restoring their cognitive function. That problem is what lead Dr. Gaufin to team up with Dr. Fong and Dr. Allen in the creation of Cognitive FX. Cognitive FX was able to take the research that Dr. Fong and Dr. Allen started in their Phd programs and bring it into the clinical environment.
If you've spent years bouncing between doctors, hearing that your racing heart is "just anxiety," or being told your debilitating fatigue is "all in your head," you're not alone. The average person...
If you've ever stood up and felt your heart start racing, felt lightheaded out of nowhere, or experienced brain fog so thick you couldn't finish a sentence, you might be dealing with something called...
Severe traumatic brain injury (TBI), concussion (mild traumatic brain injury or mTBI), and other head trauma can cause high blood pressure, low blood pressure, and other circulatory system changes....
Published peer-reviewed research shows that Cognitive FX treatment leads to meaningful symptom reduction in post-concussion symptoms for 77% of study participants. Cognitive FX is the only PCS clinic with third-party validated treatment outcomes.
READ FULL STUDY
