Sustained postural dizziness, palpitations, fatigue, brain fog, dyspnea and exercise intolerance.
MALMO POTS score supports clinical suspicion but is not diagnostic.
10-minute Active Stand Test with HR/BP measured every minute.
Education, oral fluids, salt, compression, graded exercise and medication when needed.
Clinical Diagnostic Algorithm
Quick pathway overview
Open this for the full at-a-glance diagnostic flow. Detailed guidance remains below.
Quick pathway overview
1. Initial Presentation
Suspect POTS in patients, especially adolescent girls and women aged 15–50, with symptoms consistently worse upright and relieved by lying down.
2. Health History Review & Initial Consultation
Confirm postural pattern, symptom duration, triggers, comorbidities, family history, fluid/salt/caffeine intake and syncope features. Complete MALMO POTS questionnaire.
High probability of POTS - proceed with Active Stand Test.
Lower probability -proceed at clinician discretion based on symptoms and comorbidities.
3. Red Flag Screen
Screen for exertional syncope, unheralded syncope, abnormal ECG, structural heart disease, SVT, family history of sudden death or new presentation over age 50.
Proceed with diagnostic pathway.
Urgent Cardiology / Emergency Department referral.
4. Active Stand Test
Supine rest 5–10 minutes, then record HR and BP every minute for 10 minutes while standing. Morning testing preferred if possible.
5. Investigations
Exclude mimics and secondary causes before confirming POTS.
6. Confirm Diagnosis
All criteria met: sustained HR rise on at least two measurements one minute apart, no classical orthostatic hypotension within the first 3 minutes, symptoms worse upright, duration ≥3 months and secondary causes considered.
7. Education & Non-Pharmacological Management
Education, trigger management, fluids, salt, compression, counter-manoeuvres, school/work support and graded exercise rehabilitation.
8. Pharmacological Management
Consider if symptoms remain limiting: nadolol, bisoprolol, propranolol, ivabradine or midodrine depending on HR, BP and tolerance.
9. Specialist Referral & Multidisciplinary Management
Cardiology, General Medicine, Physiotherapy, Breathing Physiotherapy, Clinical Exercise Physiology, Dietetics and Psychology.
1. Recognition: When to Suspect POTS
Suspect POTS in patients, especially adolescent girls and women aged 15–50, with symptoms consistently worse upright and relieved by lying down.
Symptoms should be sustained when upright and improved with sitting or lying down.
Common symptoms
- Sustained lightheadedness or dizziness on standing
- Palpitations or tachycardia on standing
- Dyspnea or chest discomfort
- Fatigue and exercise intolerance
- Brain fog or cognitive impairment
- Near-syncope; frank syncope is less common
- Tremulousness and generalised weakness
- Blurred vision
- Peripheral acrocyanosis
- Nausea, bloating or abdominal discomfort
- Headache including migraine
- Coat-hanger pain
- Sleep disturbance
Associated conditions
Clinical pearl +
2. Health History Review & Initial Consultation
Use history to establish the pattern, duration, triggers and risk profile before testing.
History checklist
- Postural relationship of symptoms
- Duration ≥3 months
- Triggers: heat, standing, alcohol, meals, exercise, menstrual cycle, rapid weight loss
- Family history of syncope, sudden cardiac death or inherited arrhythmia
- Oral fluid, salt, caffeine and dietary intake
- Syncope duration and recovery characteristics
MALMO POTS questionnaire & score evaluator
Use the MALMO POTS questionnaire as a screening tool to support clinical suspicion. It is not part of the formal diagnostic criteria.
MALMO questionnaire scoring +
Please enter the number on the scale that corresponds to your average symptoms for the past week. You should only answer once per question. If you haven’t experienced symptoms, enter zero (0).
Scale: 0 = no symptoms; 10 = most pronounced symptom.
| MAPS item | Past-week severity 0 = none, 10 = most pronounced |
|---|---|
| 1. Dizziness when upright or standing up | |
| 2. Dizziness with a feeling of near-fainting | |
| 3. Palpitations, rapid pulse, or irregular heartbeat sensation | |
| 4. Breathing difficulty / dyspnoea at rest or with effort | |
| 5. Chest pain | |
| 6. Headache | |
| 7. Difficulty concentrating and/or problems thinking | |
| 8. Muscle pain | |
| 9. Nausea | |
| 10. Gastrointestinal problems such as stomach pain, diarrhoea, or constipation | |
| 11. Abnormal tiredness that persists despite rest | |
| 12. Insomnia | |
| Total MALMO POTS score |
The total score will automatically update as each 0–10 symptom rating is entered.
MAPS item structure adapted from the Malmö POTS Score questionnaire by Skåne University Hospital/Lund University and shared by the Australian POTS Foundation. For formal use, verify wording against the official questionnaire.
Score interpretation +
- >42: high probability of POTS - proceed with Active Stand Test.
- <40: low probability - Do not proceed with Active Stand Test explore differential diagnosis.
- 40–42: intermediate/borderline — proceed with Active Stand Test at clinician discretion based on symptoms and comorbidities.
- MALMO is a screening tool only and is not part of formal diagnostic criteria.
3. Red Flag Screen
Do not manage solely in primary care when red flags are present.
Red flags
- Unheralded syncope with no prodrome
- Syncope during exertion
- Abnormal ECG: prolonged QT, pre-excitation or significant arrhythmia
- Family history of sudden cardiac death or inherited arrhythmia syndrome
- Structural heart disease on examination or history
- SVT confirmed on ECG or Holter
- Syncope in a patient >50 years without prior diagnosis
Action
Proceed with Active Stand Test and usual diagnostic pathway.
Urgent referral to Cardiology / Emergency Department.
4. Active Stand Test
Use a structured 10-minute standing protocol. Morning testing is preferred where possible.
Preparation and protocol
- Use a quiet room
- Continue usual medication unless specifically instructed otherwise
- Patient lies supine for 5–10 minutes
- Record baseline HR and BP
- Patient stands passively — no active exercise
- Record HR and BP every minute for 10 minutes
- Record symptoms during the test
- If borderline or inconsistent, consider repeat morning testing
Interpretation +
Sustained HR rise ≥30 bpm in adults, or ≥40 bpm age 12–19, within 10 minutes, with symptoms and without classical orthostatic hypotension.
A sustained BP fall ≥20/10 mmHg occurring within the first 3 minutes of standing.
A later BP fall after 3 minutes does not exclude POTS and may coexist with POTS.
Recording form
| Time | HR | BP | Symptoms |
|---|
5. Investigations
Investigations are used to exclude mimics, secondary causes and red-flag pathology.
Recommended for most patients
- 12-lead ECG
- FBC
- Iron studies
- Thyroid function tests
- HbA1c or fasting glucose when clinically indicated
- Electrolytes and renal function
Exclude secondary causes
- Anaemia
- Hyperthyroidism
- Dehydration or volume depletion
- Primary adrenal insufficiency
- Fever or active infection
- Malnutrition or sudden weight loss
6. Confirm POTS Diagnosis
All criteria should be present before confirming POTS.
Diagnostic criteria
- Sustained HR increase ≥30 bpm within 10 minutes of upright posture
- Sustained increase means the heart-rate rise is seen on at least two measurements made at least one minute apart during the 10-minute standing period
- Use ≥40 bpm threshold for adolescents aged 12–19
- No classical orthostatic hypotension within the first 3 minutes of standing
- Symptoms of orthostatic intolerance worse upright and improving with recumbence
- Duration ≥3 months
- Secondary causes considered and treated/excluded where relevant
Differential diagnosis
- Orthostatic hypotension
- Inappropriate sinus tachycardia
- Vasovagal syncope
- Orthostatic intolerance without tachycardia, including in ME/CFS
- Anxiety or panic disorder
- Deconditioning
7–8. Management
Use stepwise management, beginning with education and non-pharmacological strategies for all patients.
Education & trigger management
- Explain POTS is treatable and not life-threatening
- Rise slowly from lying or sitting
- Avoid heat, hot baths/showers and prolonged standing
- Avoid alcohol and dehydration
- Consider small frequent meals and avoiding large carbohydrate-heavy meals
- Provide support for school, workplace or education accommodations where appropriate
Fluids & salt
- Oral fluids: 2–3 litres/day unless contraindicated
- Salt: 8–10 g salt/day where appropriate
- Use caution in hypertension, heart failure or renal disease
- Review adherence at 4–6 weeks
Compression garments
- Waist-high sports-grade compression garments or sports-grade compression shorts
- Abdominal binders may be more tolerable for some patients
- Knee-high compressions are often less effective than abdominal/waist-high compression
Exercise rehabilitation
- Begin with horizontal or recumbent exercise to reduce orthostatic stress
- Options: swimming, recumbent cycling, rowing ergometer
- Progress gradually to upright exercise over weeks to months
- Include strength training as tolerated
- Include breathing retraining where dysfunctional breathing is present
- Refer to physiotherapy or clinical exercise physiology if needed
Recumbent / horizontal
Swimming, recumbent bike, rowing.
Semi-recumbent
Progress volume and tolerance before upright loading.
Upright exercise
Walking, gym-based training and return to sport/activity as tolerated.
Pharmacological management
Medication should be individualised. All pharmacotherapy for POTS is off-label in New Zealand.
First line — low-dose beta-blocker
- Examples: propranolol, bisoprolol or nadolol
- Suggested maximum daily doses: propranolol 20 mg TDS, bisoprolol 5 mg daily, nadolol 20 mg daily
- Particularly useful where awareness of tachycardia is prominent
- May increase fatigue and reduce blood pressure
Second line — ivabradine
- Consider if beta-blocker is ineffective or not tolerated
- Reduces HR without lowering BP as much as beta-blockers
- Currently unfunded in New Zealand
Second line — fludrocortisone
- Volume expander
- Useful when lightheadedness or fatigue predominate and BP is low-normal
- Consider if salt supplements are not tolerated
- Counsel patients that high blood pressure, fluid overload and hypokalaemia are uncommon in POTS but remain potential adverse effects that should be discussed and monitored when clinically appropriate
Second line — midodrine
- Increases venous tone
- Short acting and often requires dosing at least three times daily
- Requires Special Authority in New Zealand
- Avoid near bedtime; counsel regarding supine hypertension, scalp tingling and piloerection
Monitoring: HR, BP, fatigue and medication-specific adverse effects.
9. Specialist Referral & Multidisciplinary Management
Referral pathways vary by region across New Zealand. Refer when red flags, diagnostic uncertainty, refractory symptoms or complex comorbidities are present.
Referral indications
- Red flag features
- Diagnostic uncertainty after primary care assessment
- Poor response after 3–6 months of appropriate management
- Complex comorbidities requiring coordinated care
NZ referral options
Follow-up Schedule
Suggested review points for ongoing monitoring.
Review oral fluids, salt, triggers, compression, exercise adherence and symptoms.
Repeat Active Stand Test; review medication response, symptoms and function.
Assess stability, functional goals and multidisciplinary input.
Review ongoing needs, comorbidities and medication requirement.
Earlier review if red flags, deterioration or diagnostic uncertainty develops.
References & Further Reading
Key clinician resources supporting this pathway.
- Postural Orthostatic Tachycardia Syndrome: State-of-the-Art Review
- Australian POTS Foundation — diagnostic tools and clinician resources
- Heart Rhythm Society Expert Consensus Statement
- Diagnosis and management of POTS — primary care review
- Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance
Contributors, disclosure and guideline information
Guideline development
This guideline was developed by the Dysautonomia New Zealand Foundation to support healthcare professionals in the recognition, assessment and management of postural orthostatic tachycardia syndrome (POTS) in New Zealand.
The guideline incorporates current evidence, international clinical guidance, consensus statements and multidisciplinary clinical expertise relevant to the New Zealand healthcare setting.
Contributors
The Dysautonomia New Zealand Foundation acknowledges the clinicians and allied health professionals who contributed to the development, review and refinement of this guideline.
Contributors
| Dr Ellie Rickman, PhD | Clinical Exercise Physiologist (Project Lead) |
| Scott Pierce | Physiotherapist |
| Brooke Pierce | Physiotherapist |
| Greer Pugh | Researcher |
| Dr Jenny Butler | General Medicine Physician |
| Dr Fiona Stewart | Cardiologist |
| Dr Ross Nicholson | Cardiologist |
| Dr Marie-Claire Seeley, PhD | Chief Executive Officer, Australian POTS Foundation | Professor Julian Paton, PhD | The University of Auckland; Faculty of Medical and Health Sciences, Physiology, New Zealand |
Disclosure
Contributors participated in the development of this guideline in an independent professional capacity and were asked to declare relevant conflicts of interest. No commercial organisation or pharmaceutical company influenced the guideline recommendations.
Disclaimer
This guideline is intended to support, not replace, clinical judgement. Recommendations should be considered alongside individual patient circumstances, clinician expertise, patient preferences and current evidence.
Recommended citation
Dysautonomia New Zealand Foundation. New Zealand Clinical Guideline for the Recognition, Assessment and Management of Postural Orthostatic Tachycardia Syndrome (POTS). Version 1.0. Auckland, New Zealand: Dysautonomia New Zealand Foundation; 2026.
Publication date: July 2026
Scheduled review: July 2028, or earlier if significant new evidence becomes available.