Recorded on July 16, 2026
Postural Orthostatic Tachycardia Syndrome (POTS) has become an increasingly common reason for referral to pediatric cardiology, particularly since the COVID-19 pandemic. Social media awareness has also led many adolescents and families to arrive in clinic convinced they have POTS, making it more important than ever for primary care providers to understand the condition, recognize its diagnostic criteria, and distinguish it from more serious cardiac disorders.
During a recent CHKD CME Lunch & Learn, pediatric cardiologist Dr. Tracy Alderson shared a practical approach to evaluating adolescents with orthostatic symptoms, emphasizing that while POTS itself is not a primary cardiac disease, a thorough cardiac evaluation is essential to exclude potentially life-threatening conditions before making the diagnosis.
POTS Is a Diagnosis of Exclusion
One of the most important takeaways is that POTS should never be considered the default diagnosis for a patient presenting with dizziness or tachycardia.
According to Dr. Alderson, the cardiologist's primary role is to rule out conditions such as:
- Supraventricular tachycardia (SVT)
- Cardiomyopathy
- Primary arrhythmias
- Structural heart disease
She shared examples of patients initially thought to have POTS who were ultimately diagnosed with Brugada syndrome and dilated cardiomyopathy, reinforcing the importance of a comprehensive cardiac evaluation before settling on an autonomic diagnosis.
Understanding the Diagnostic Criteria
POTS is characterized by persistent orthostatic symptoms lasting three to six months accompanied by:
- An increase in heart rate of 40 beats per minute or more within 10 minutes of standing (for adolescents)
- No accompanying orthostatic hypotension
- Symptoms that improve when the patient is supine
Common symptoms include:
- Lightheadedness
- Fatigue
- Brain fog
- Nausea
- Exercise intolerance
- Heat sensitivity
- Palpitations
Interestingly, syncope is not required for diagnosis and is often absent. Instead, many patients experience chronic presyncopal symptoms that significantly impact daily functioning.
Many Conditions Can Mimic POTS
Because orthostatic tachycardia has numerous potential causes, providers should carefully evaluate for conditions that may present similarly, including:
- Anxiety disorders
- Physical deconditioning
- Sleep disorders
- Eating disorders
- Dehydration
- Hyperthyroidism
- Anemia
- Medication or supplement effects
- Substance use
- Excessive caffeine or energy drink consumption
Dr. Alderson noted that identifying and addressing these underlying contributors often improves symptoms without additional intervention.
Start With Conservative Treatment
While medications may be appropriate for select patients, lifestyle interventions remain the cornerstone of treatment.
Key recommendations include:
- Drinking 80–100 ounces of water or electrolyte-containing fluids daily
- "Water loading" with 24–32 ounces shortly after waking
- Eliminating or significantly reducing energy drinks and caffeine
- Participating in structured exercise at least five days per week
- Addressing sleep quality
- Evaluating for disordered eating
- Treating constipation and dysmenorrhea when present
Dr. Alderson also highlighted the effectiveness of the CHOP Modified Dallas POTS Exercise Program, which emphasizes gradual cardiovascular conditioning and strength training without provoking symptoms.
Exercise Is Medicine
One of the lecture's strongest messages was that activity restriction often worsens symptoms.
Rather than recommending prolonged rest or homebound instruction, providers should encourage patients to remain engaged in school and physical activity whenever possible. School accommodations such as unrestricted access to water, restroom breaks, extra time between classes, and occasional rest periods may be appropriate, but complete avoidance of exercise can contribute to further deconditioning and symptom progression.
Before Referring to Cardiology
Dr. Alderson recommends completing several basic evaluations before referral, including:
- Electrocardiogram (EKG)
- Complete blood count (CBC)
- Basic metabolic panel (BMP)
- Thyroid studies
- Vitamin D level
- Review of BMI trends for weight loss
- Screening for constipation, dysmenorrhea, sleep disorders, and mental health concerns
Initiating hydration strategies and exercise recommendations before the cardiology appointment can also help patients begin improving symptoms sooner.
The Bottom Line
POTS is increasingly recognized in pediatric patients, but successful management begins with careful evaluation and exclusion of serious cardiac disease. Once dangerous causes have been ruled out, most patients benefit from education, hydration, exercise, improved sleep, and treatment of contributing conditions before medications are considered.
As awareness of POTS continues to grow, providers play a critical role in helping families navigate an often confusing diagnosis while guiding patients toward evidence-based strategies that improve symptoms and restore function.
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