Postural orthostatic tachycardia syndrome (POTS) currently requires orthostatic intolerance with a heart rate rise of at least 30 beats per minute in adults (40 in adolescents) within 10 minutes of standing or tilt. Many patients with the same symptoms and disability fall short of that number and go undiagnosed.
This international Delphi consensus, with 40 contributors from seven countries including patient advocates, voted on 31 statements covering recognition, diagnosis, treatment and research. All reached more than 90% agreement and 24 were unanimous. A recurring theme was the need for a standard nomenclature that includes non-POTS dysautonomia.
This is expert opinion rather than new trial evidence. Its value for the general physician is in taking orthostatic symptoms seriously, doing a proper active stand test, and not dismissing a patient because the heart rate rise is 25 rather than 30.
- Do a 10-minute active stand test, recording heart rate and blood pressure at 1, 3, 5 and 10 minutes, in anyone with orthostatic symptoms.
- A rise below 30 beats per minute does not exclude autonomic dysfunction if symptoms and disability are typical.
- Exclude dehydration, anaemia, thyroid disease, medication effects and deconditioning before labelling dysautonomia.
- Start with fluids, salt where safe, compression garments and graded recumbent exercise.
- Ask about preceding viral illness, including COVID-19 — a common trigger.
Why it matters
It widens the door for patients who have been told their tests are normal despite real orthostatic disability.
Don't overread it
This is a Delphi expert consensus, not trial evidence, and the proposed broader criteria have not been validated.
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