POTS and the Autonomic Nervous System: A Post-COVID Rise in Dysregulation

Postural Orthostatic Tachycardia Syndrome (POTS) is a condition where your autonomic nervous system struggles to regulate blood flow and heart rate properly when you stand up, leading to an exaggerated increase in heart rate (tachycardia) without a corresponding drop in blood pressure. This dysregulation can cause symptoms like dizziness, fatigue, brain fog, and even fainting. It’s as if your body is a finely tuned orchestra, but the conductor (your autonomic nervous system) loses control when you stand, and the percussion section (your heart) starts playing wildly out of sync, leaving the rest of the orchestra struggling to keep up. Instead of maintaining harmony, your body is left scrambling to balance blood flow to your brain and other organs, which can leave you feeling drained and off-kilter.

In this article, we will cover the higher incidence found in women and people with hypermobile Ehlers-Danlos Syndrome (hEDS), how to make the diagnosis of POTS, and current treatment options.

In my precision medicine practice at the Marcus Institute of Integrative Health at Thomas Jefferson University, I witnessed a significant increase in POTS during and after the pandemic. I’ve written extensively about the autonomic nervous system dysfunctions that I see in my medical practice, and I would put POTS at the more extreme range of the spectrum of autonomic dysfunction.

Post-Pandemic Increase in POTS

Research shows that the incidence of POTS has risen significantly during and after the COVID-19 pandemic, largely linked to the long-term effects of viral infections on the autonomic nervous system. Research has shown that POTS often develops following viral illnesses, and COVID-19 has proven to be a particularly potent trigger due to its systemic inflammatory effects and potential disruption of blood flow regulation. Studies suggest that post-COVID autonomic dysfunction may lead to the hallmark symptoms of POTS, including rapid heart rate, dizziness, and fatigue, even in previously healthy individuals. This surge in cases has highlighted the need for greater awareness and resources to support those affected. Early recognition, lifestyle modifications, and evidence-based interventions have become increasingly important in addressing this growing health challenge.

Specifically, recent studies have shown a significant rise in POTS cases among individuals recovering from COVID-19, with estimates suggesting that 2%-14% of COVID-19 survivors develop POTS, and 9%-61% experience POTS-like symptoms such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months post-infection. The pathophysiological mechanisms are not fully understood but may include autoimmunity, autonomic dysfunction, direct toxic injury to the autonomic nervous system, and central nervous system invasion by SARS-CoV-2.

Additionally, Seeley et al. (2023) reported a high incidence of autonomic dysfunction and POTS in patients with long COVID, emphasizing the need for routine autonomic testing in these patients to aid diagnosis and management.

Gómez-Moyano et al. (2023) also highlighted the occurrence of POTS and other dysautonomic disorders following SARS-CoV-2 infection and COVID-19 vaccination, underscoring the importance of recognizing and managing these conditions.

The increasing incidence of POTS is likely due to the widespread impact of COVID-19, which has led to a higher prevalence of post-acute sequelae, including autonomic dysfunction. This underscores the need for heightened awareness and appropriate management strategies for POTS in the context of our post-pandemic world.

POTS More Common in Women

Postural Orthostatic Tachycardia Syndrome (POTS) is significantly more common in women, with around 80–90% of cases occurring in females, particularly those of childbearing age. This gender disparity is influenced by several mechanisms, including hormonal fluctuations in estrogen and progesterone, and differences in autonomic regulation.

Hormonal Fluctuations: Estrogen and progesterone, which fluctuate throughout the menstrual cycle, can affect blood vessel tone and autonomic regulation. Fu et al. found that during the mid-luteal phase of the menstrual cycle, when estrogen and progesterone levels are high, women with POTS had better compensated hemodynamics compared to the early follicular phase. This suggests that hormonal fluctuations modulate the renin-angiotensin-aldosterone system, leading to improved volume retention and orthostatic tolerance during the mid-luteal phase, though there is not substantive recent research in this field.

Sympathetic Neural Activity: Bonyhay and Freeman demonstrated that women with POTS exhibit increased sympathetic activity at rest, with a greater relative contribution of burst frequency to total muscle sympathetic nerve (MSN) activity during hypotension compared to men. This heightened sympathetic response may contribute to the higher prevalence of POTS in women.

Blood Pressure and Vasoconstriction: Stickford et al. found that while the menstrual cycle does not affect muscle sympathetic nerve activity, it does modulate blood pressure and vasoconstriction in women with POTS during orthostatic stress. This indicates that factors other than sympathetic neural activity, such as hormonal influences, are likely responsible for the symptoms of orthostatic intolerance across the menstrual cycle in women with POTS.^[3]

In summary, the higher prevalence of POTS in women, particularly those of childbearing age, is influenced by hormonal fluctuations affecting blood vessel tone and autonomic regulation, as well as differences in sympathetic neural activity and blood pressure modulation. These mechanisms collectively contribute to the gender disparity observed in POTS.

POTS Commonly Coexists with Hypermobile Ehlers-Danlos Syndrome (hEDS)

POTS frequently coexists with hypermobile Ehlers-Danlos Syndrome (hEDS), a connective tissue disorder. People with hEDS often experience joint hypermobility and fragile connective tissue, which can impair venous return and contribute to the blood pooling seen in POTS. The overlap between POTS and hEDS suggests a shared underlying mechanism involving dysregulated autonomic function and connective tissue fragility. Together, these findings highlight the importance of a multidisciplinary approach to treatment, especially for women and those with conditions like hEDS who may face unique challenges in managing POTS.

Diagnosis

Diagnosing Postural Orthostatic Tachycardia Syndrome (POTS) typically involves a combination of clinical history, physical examination, and specific testing. Key diagnostic criteria include:

1. Heart Rate Increase: A sustained increase in heart rate of ≥30 beats per minute (or ≥40 bpm in adolescents) within 10 minutes of standing or during a tilt-table test, without significant drop in blood pressure.
2. Symptoms: Accompanying symptoms like dizziness, lightheadedness, fatigue, palpitations, nausea, or brain fog when upright.
3. Ruling Out Other Causes: Exclusion of other conditions that could explain the symptoms, such as dehydration, anemia, or thyroid dysfunction.

Testing often includes:

1. Tilt-Table Test: Evaluates heart rate and blood pressure responses to changes in posture.
2. Active Stand Test: Monitors heart rate and blood pressure changes while standing.
3. 24-Hour Holter Monitor: Assesses heart rhythm over a longer period to rule out arrhythmias.

Additional tests like blood volume assessments, autonomic function testing, or bloodwork (to check for underlying conditions such as autoimmune disorders) may be performed depending on clinical suspicion.

Treatment

The treatment of Postural Orthostatic Tachycardia Syndrome (POTS) focuses on managing symptoms and improving quality of life through a combination of lifestyle modifications, medications, and targeted therapies. The most evidence-based treatments include:

Lifestyle Interventions

1. Increased Fluid and Salt Intake: Enhancing blood volume is a cornerstone of POTS management. Patients are often advised to drink 2–3 liters of water daily and consume 3–10 grams of salt per day, depending on individual needs.
   • Evidence: This strategy has been shown to improve orthostatic tolerance and reduce symptoms. (Garland et al., 2015)
2. Compression Garments: Wearing thigh-high or waist-high compression stockings can help prevent blood pooling in the lower extremities, alleviating dizziness and fatigue.
   • Evidence: Compression therapy improves hemodynamic stability in POTS. (Fu et al., 2010)
3. Physical Conditioning: A structured, graduated exercise program focused on recumbent aerobic exercise (e.g., swimming, rowing) and resistance training can improve autonomic function and increase blood volume.
   • Evidence: Exercise training has been shown to reduce heart rate and improve symptoms in POTS patients. (Fu et al., 2011)

Medications

4. Beta-Blockers: Low-dose beta-blockers, such as propranolol or metoprolol, can reduce excessive heart rate and improve symptoms.
   • Evidence: Studies show they are effective, particularly in younger patients. (Raj et al., 2009)
5. Fludrocortisone: This mineralocorticoid helps increase blood volume by promoting sodium retention.
   • Evidence: Used in patients with hypovolemia, fludrocortisone has been shown to reduce orthostatic symptoms. (Garland et al., 2015)
6. Midodrine: An alpha-agonist that increases vascular tone and prevents blood pooling.
   • Evidence: Midodrine is particularly helpful in improving orthostatic blood pressure. (Raj et al., 2014)
7. Ivabradine: This heart rate-lowering medication may be used in patients with severe tachycardia symptoms.
   • Evidence: Emerging evidence suggests it can reduce symptoms in POTS patients. (Taub et al., 2021)

Behavioral and Dietary Adjustments

8. Small, Frequent Meals: Reducing postprandial blood pooling by eating smaller meals high in protein and low in simple carbohydrates can prevent symptom flares.
   • Evidence: Blood pooling after meals exacerbates POTS symptoms. (Freeman et al., 2011)
9. Sleep Position: Sleeping with the head of the bed elevated can help improve overnight blood volume regulation.
   • Evidence: This technique has shown benefits in managing orthostatic intolerance. (Garland et al., 2015)

Emerging Therapies

10. Vagus Nerve Stimulation: Preliminary evidence suggests that vagus nerve stimulation may help modulate autonomic function.

• Evidence: Small studies are currently exploring its efficacy. (Miller et al., 2021)

By combining these strategies and personalizing the approach, many patients experience significant symptom improvement. Close monitoring and regular follow-up with healthcare providers are essential to ensure treatments remain effective.

Conclusion

Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic autonomic nervous system disorder characterized by excessive tachycardia upon standing and a range of debilitating symptoms. Recent scientific literature from 2020-2025 has provided further insights into the pathophysiology, management, and increasing incidence of POTS. 

Living with POTS, especially in the wake of the pandemic, can feel overwhelming—like your body is working against you with every step. But here’s the truth: there is real hope. Science is catching up, and more is known about POTS today than ever before. With the right combination of lifestyle changes, targeted therapies, and persistence, many people are not just surviving but thriving with POTS. Your body is adaptable, and with time, you can retrain it to find balance again. Fainting or struggling now doesn’t define your future. Each small step, whether it’s hydrating more, building strength, or finding the right medication, is a step toward reclaiming your vitality. You’re not alone in this journey, and there’s a growing community of researchers, clinicians, and fellow patients ready to help you rise above the challenge. Healing is possible, and your body has incredible potential to recover.