condition
POTS and Dysautonomia
POTS — postural orthostatic tachycardia syndrome — is a disorder of the autonomic nervous system, the part of you that runs heart rate, blood pressure, digestion and temperature without being asked. It is not a heart condition.
The racing heart is not the problem
When you stand, gravity pulls blood down into your legs. A healthy autonomic nervous system tightens the leg vessels and pushes it back up. In POTS that signal is weak or missing, blood pools, and the heart speeds up to keep circulation going.
So the tachycardia is the body coping. Treatment aimed only at slowing the heart removes the compensation without touching the cause, which is why people often feel worse rather than better. Our job is to find out what the heart rate is compensating for.
What POTS looks like
Fatigue that is worse on standing, and worse after exertion — sometimes a day or two later
Lightheadedness, or feeling about to pass out when you stand
Palpitations or a pounding heart on standing
Brain fog — losing words, cloudy thinking, not holding a thought
Nausea and bloating
Blurred vision
Shakiness
Chest pain and breathlessness
Cold or numb hands and feet
Acrocyanosis — dusky blue-purple mottling of the legs after standing
Why it mostly affects young women
About eighty percent of people with POTS are female, most diagnosed between seventeen and thirty-five. The reason is not fragility. It is fine tuning.
A man holds his blood pressure on standing mostly by tightening his vessels, with blood volume to spare. A woman holds hers by raising her heart rate, on a smaller blood volume, in a more elastic vascular bed that hormones recalibrate every month — and on top of that, decades of monthly iron loss, stretchier connective tissue, and an autoimmune risk that is itself eighty percent female.
So POTS is not a broken system. It is a normal orthostatic strategy that has run out of reserve. Margin is what we can give back.
How we confirm it
We look for a heart rate rise of thirty beats per minute or more within ten minutes of standing — forty in adolescents — with no significant drop in blood pressure, and symptoms that have lasted months rather than days.
That middle point is the one that matters. In POTS the heart races and the pressure holds. In orthostatic hypotension the pressure is what gives way. In vasovagal syncope the rate climbs, then crashes, and you faint.
There is more than one kind
The subtypes do not respond to the same treatment.
Neuropathic — damaged small nerve fibers, so the leg vessels never get the signal to constrict. About half of cases.
Hypovolemic — low blood volume the body fails to correct. Around seventy percent.
MCAS-associated — mast cell activation, with episodic flushing and dizziness and good days and bad days. Around forty-five percent, and the one most often called anxiety.
Post-viral — nerve damage and autoantibodies running at once. About a third of new cases, rising sharply since 2020.
Autoimmune — around eighteen percent, and rising.
Hyperadrenergic — about ten percent.
How we work out what is going on
Bloodwork, ECG and echocardiogram are usually unremarkable in POTS. That does not mean nothing is wrong. It means those tests measure analytes, and POTS is a disorder of regulation.
So alongside a long history and serum and functional laboratory testing, we measure regulation directly: heart rate variability for autonomic tone, bioimpedance for cellular hydration and phase angle, live and dried blood analysis for the terrain itself, and bioenergetic testing with QUEX, OMNIS and the Kvantum Bioscan.
The order matters more than the treatments
Almost everything used for POTS is on somebody’s protocol somewhere. What usually goes wrong is the sequence.
Stabilize the terrain. Daylight early, time outdoors and barefoot on the ground, slow nasal breathing, hydration with minerals rather than water alone, sleep. It costs nothing, and it is where we start with nearly everyone.
Stabilize the nervous system. Vagal toning, breathing work, HRV biofeedback, gemmotherapy, flower essences, referral for limbic retraining.
Stabilize the mast cells, where they are part of the picture.
Only then detoxify and drain — and only then rebuild according to subtype.
What we use
Gemmotherapy — remedies made from plant bud tissue, working at the level of tissue and terrain rather than pushing on a receptor. One of our most-used tools here.
Drainage and spagyric remedies — open the routes of elimination so what gets stirred up can actually leave.
Flower essences — for the limbic and trauma layer of this syndrome.
Vagal toning and breathing — chosen by your heart rate variability, because a practice that heals one person pushes another further into dysregulation.
Volume and mechanical support — real electrolytes and minerals, IV therapy, compression, elevating the head of the bed.
Mitochondrial and nutrient repletion — a nervous system in energy deficit cannot regulate, whatever else it is given.
Graded movement, recumbent first
Hyperbaric oxygen for nerve repair and post-illness fatigue. Hyperbaric oxygen therapy
IV therapy and ozone where they are indicated. IV therapy · Ozone therapy
Referral, deliberately — limbic retraining, upper cervical chiropractic, craniosacral therapy and skilled physical therapy are part of how these patients get better.
What can make POTS worse
Salt is not right for everyone. In hyperadrenergic POTS — about one in ten — blood pressure rises rather than holds on standing, and volume loading, licorice root and blood-pressure-raising medication can all backfire. This is why we subtype before we treat.
Pushing exercise costs months.
Not everyone is ready to detoxify. When heart rate variability and phase angle are very low, that is a stop sign. Food, fluids, minerals, daylight and rest come first.
Being straight with you
Most people find this page after being told their tests are normal, and a good number after being told this is anxiety. It is not. It is a measurable problem in a measurable system, and ten minutes with a blood pressure cuff will usually show it.
What we cannot promise is speed. Getting the sequence right means the early work looks unimpressive — daylight, minerals, breathing, sleep — and the interesting treatments come later, once your body can afford them. In that order, ordinary treatments start working. In the wrong order, good ones make people worse.
You have usually been dismissed. We will look underneath the hood.
Common questions
Is POTS a heart condition?
No. POTS is a disorder of the autonomic nervous system. The heart is responding normally to an abnormal signal — the racing heart rate is a compensation, not the underlying problem.
Is POTS just anxiety?
No. POTS is confirmed objectively, with a heart rate and blood pressure measurement on standing. Anxiety does not care what position you are in; POTS symptoms are triggered by standing and settle on lying down. Most of our POTS patients have been told at some point that this was anxiety.
Can I have POTS if all my tests came back normal?
Yes, and most people do. Bloodwork, ECG and echocardiogram are usually unremarkable in POTS. They are worth doing to exclude other things, but they are not what confirms it.
Do I need a tilt table test?
No. An active stand test in the office meets the diagnostic criteria. Where that is equivocal we use the NASA lean test, which approximates a tilt table with nothing but a wall.
Can POTS come on after COVID or another virus?
Yes — about a third of new cases, and rising sharply since 2020. Sudden onset after a viral illness in someone previously healthy and active is the classic picture.
Does POTS ever go away?
Yes, it can. POTS is a syndrome rather than a permanent diagnosis — a pattern with something driving it. When the driver is found and treated, the pattern can resolve. How completely and how quickly depends on what is underneath it and how long it has been going on.
How long does treatment take?
Monthly visits to begin with, then every other month as we work on the deeper patterns, then quarterly for maintenance. The pace is set by what your nervous system can tolerate rather than by the calendar — if the work is moving faster than you can absorb it, we slow down.
Do you treat teenagers with POTS?
Yes. The diagnostic threshold is different in adolescents — forty beats per minute rather than thirty — and the average age at diagnosis is in the late teens.
Is this covered by insurance?
We do not participate with any form of insurance, including Medicare. If you are accepted into the practice we can create superbills on request as a courtesy.
How do I start?
Begin with the New Patient Questionnaire. Schedule an appointment
Reviewed by Dr. Chris Chlebowski, ND.
