Your heart pounds when you stand up. The room goes gray in the shower. You can’t stand in a checkout line without needing to sit down. None of this happened before you had COVID.
If that sounds familiar, you may be dealing with postural orthostatic tachycardia syndrome (POTS), one of the most commonly reported forms of autonomic dysfunction after COVID. It is real, it is measurable, and it is frequently missed.
What POTS is
Your autonomic nervous system handles what you never think about, including heart rate, blood pressure, blood vessel tone, and digestion. When you stand, it tightens blood vessels in your lower body so blood keeps reaching your brain.
In POTS, that adjustment doesn’t work well. Blood pools in the lower body, and the heart races to compensate.
The 2015 Heart Rhythm Society expert consensus describes POTS as:
- a sustained heart rate increase of 30 or more beats per minute within 10 minutes of standing (40 or more for ages 12–19),
- without a significant drop in blood pressure,
- with symptoms lasting at least three months.
Common symptoms
- Racing or pounding heartbeat on standing
- Lightheadedness, near-fainting, or fainting
- Shakiness or an adrenaline-like feeling
- Fatigue that is worse when upright
- Brain fog, especially while standing or sitting up for long periods
- Exercise intolerance
- Nausea, bloating, or changes in bowel habits
- Cold or discolored hands and feet, or reddish-purple legs when standing
Why it can show up after COVID
Researchers are still working out why some people develop POTS after a viral infection. Proposed explanations include:
- immune activity that affects the nervous system,
- inflammation affecting blood vessels, and
- deconditioning during a long illness.
Most likely, more than one factor plays a role, and the mix differs from person to person. Estimates of how often POTS follows COVID vary widely between studies. What is consistent is that orthostatic intolerance shows up again and again in long COVID research.
Why it gets missed
A standard visit usually measures heart rate and blood pressure while you’re sitting. POTS only shows itself when you stand. An EKG, an echocardiogram, and routine bloodwork can all come back normal. Many people are told they’re anxious or deconditioned and sent home.
Anxiety and deconditioning can overlap with POTS. Neither explains a heart rate that climbs 40 beats every time you stand.
How it is evaluated
A thorough evaluation looks at the full picture, not just a single number:
- Your timeline: when symptoms started, what makes them worse, and how they relate to your COVID infection.
- Orthostatic vital signs: heart rate and blood pressure lying down and then at intervals while standing. This is often called an active stand test.
- Prior testing: reviewing what’s already been done, so you don’t repeat tests unnecessarily.
- Ruling out look-alikes: anemia, thyroid problems, dehydration, medication effects, and heart rhythm disorders can all mimic POTS.
- Coordination: when a tilt table test or cardiology workup is warranted, we help you get there and stay connected with your other clinicians.
POTS rarely travels alone
After COVID, POTS often overlaps with other problems: brain fog, exhaustion after exertion, gut symptoms, and new reactions to foods or smells. Looking at these together usually tells you more than chasing each symptom separately. Our Long COVID Treatment in Oklahoma City page explains how we approach the whole pattern.
For POTS that didn’t start with COVID, see POTS in Oklahoma City.
A note on self-management
Fluid and salt intake, compression garments, and gradual changes in position come up often in POTS discussions. They aren’t right for everyone. People with high blood pressure, kidney disease, or heart conditions need individual guidance. Talk with a clinician before making changes.
When to get emergency care
Call 911 or go to the nearest emergency room if you have:
- chest pain or pressure,
- fainting that causes an injury,
- fainting during exercise,
- shortness of breath at rest, or
- signs of a stroke, such as facial drooping, arm weakness, or slurred speech.
Serving Oklahoma City, Tulsa, and all of Oklahoma
Venturis Clinic is located in Oklahoma City and sees patients from Oklahoma City and surrounding areas, including Tulsa. Many patients with post-COVID POTS travel from across Oklahoma because they’ve struggled to find a clinician who takes these symptoms seriously.
Frequently asked questions
Can POTS after COVID go away? Many people improve over time, but the course varies. An evaluation helps clarify what is driving your symptoms and what to track.
Is POTS a heart problem? POTS involves the heart rate, but it is generally considered a disorder of the autonomic nervous system rather than a structural heart disease. Other heart conditions should still be ruled out.
I was told my EKG and echo are normal. Could it still be POTS? Yes. Those tests are usually normal in POTS. The key finding appears when you move from lying down to standing.
Do I need a tilt table test? Not always. An active stand test is often a useful first step. A tilt table test may be recommended in some cases.
Ready to find out what’s driving your symptoms? Book a free 15-minute discovery call, or learn more about long COVID care in Oklahoma City.
This page is for educational purposes and is not a substitute for individual evaluation.
By Alvin Philipose, DC, ICCP
Sources
- Sheldon RS, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41–e63.
- Thaweethai T, et al. Development of a definition of postacute sequelae of SARS-CoV-2 infection. JAMA. 2023;329(22):1934–1946.