POTS, or postural orthostatic tachycardia syndrome, is a nervous system disorder that causes your heart rate to spike abnormally when you stand up. It has become one of the more recognizable complications of long COVID, with estimates suggesting that 2% to 14% of COVID survivors develop the condition and up to 61% experience POTS-like symptoms within six to eight months of infection. The core problem is a malfunction in the part of your nervous system that automatically regulates heart rate, blood pressure, and blood flow when you change positions.
How COVID Triggers POTS
Your autonomic nervous system handles things you never think about: adjusting blood pressure when you stand, directing blood flow to your gut after a meal, regulating your body temperature. SARS-CoV-2 can disrupt this system through several overlapping pathways, and researchers believe most cases involve more than one of them at the same time.
The first is simple deconditioning and fluid loss. COVID often comes with prolonged fever, night sweats, and extended bed rest, all of which reduce blood volume and weaken the heart’s ability to pump efficiently against gravity. The virus also binds to ACE2 receptors throughout the body, which throws off the hormone system that controls fluid balance, potentially making the low blood volume problem worse.
The second pathway is direct nerve damage. Like other coronaviruses, SARS-CoV-2 can spread into the nervous system and damage the nerves that regulate heart rate and blood vessel tone. This can happen through direct viral invasion or through the intense inflammatory response (sometimes called a cytokine storm) that severe infection triggers.
The third involves autoimmunity. The immune response to COVID can produce antibodies that mistakenly attack the body’s own autonomic nerve receptors. This kind of “friendly fire” disrupts the signaling between your brain and cardiovascular system, and it can persist long after the virus itself is cleared.
What It Feels Like
The hallmark symptom is a racing heart when you stand up, but POTS rarely stops there. The most common complaints are rapid heartbeat, headaches, brain fog, shortness of breath, and crushing fatigue. Many people also experience dizziness, lightheadedness, or feeling like they might faint. These symptoms typically worsen with standing, heat exposure, or physical exertion and improve when lying down.
Brain fog deserves special mention because it’s often the most disabling symptom in daily life. People describe difficulty concentrating, trouble finding words, and a sense that their thinking is slower than normal. This cognitive impairment tends to be worse on days when other POTS symptoms flare.
Who Gets It
POTS has always disproportionately affected women. Before the pandemic, roughly 94% of diagnosed cases were female, with a 5-to-1 female-to-male ratio. The average age of symptom onset is around 21, and about half of people first develop symptoms during adolescence, with a peak around age 14. COVID has expanded the pool of people affected, but the demographic pattern remains similar.
One persistent problem is diagnostic delay. Women with POTS wait an average of five years from symptom onset to diagnosis, compared to three years for men. This gap likely reflects the tendency for POTS symptoms to be dismissed as anxiety or deconditioning, especially in younger women.
How POTS Is Diagnosed
The diagnostic threshold is specific: your heart rate must increase by more than 30 beats per minute (or exceed 120 beats per minute) within 10 minutes of standing, without a significant drop in blood pressure. For adolescents, the threshold is higher, at least 40 beats per minute.
Doctors typically use a tilt table test or an active standing test to measure this. One accessible version you can discuss with your doctor is the NASA Lean Test: you lie down for at least five minutes while your heart rate and blood pressure are recorded, then stand with your shoulder blades resting against a wall in a relaxed position. Heart rate and blood pressure are measured every minute for 10 minutes. Research shows that at least five minutes of standing are needed to detect the characteristic changes. This test won’t replace a formal evaluation, but it can provide useful data to bring to an appointment.
Managing Symptoms With Diet and Fluids
Increasing salt and fluid intake is typically the first recommendation. A Heart Rhythm Society expert consensus statement recommends 10,000 to 12,000 milligrams of salt per day (equivalent to about 4,000 to 4,800 milligrams of sodium) for people with POTS. That’s roughly two to three times what most adults consume. For context, a teaspoon of table salt contains about 2,300 milligrams of sodium, so this target requires deliberate effort.
People whose sodium levels test low may be advised to supplement with 1,000 to 2,000 milligrams of sodium three times daily. Electrolyte drinks, salt tablets, and simply adding salt to food are all common strategies. The goal is to expand blood volume so your body has an easier time maintaining blood pressure when you stand.
The Exercise Approach
Exercise is one of the most effective long-term treatments, but it has to be done carefully. The standard approach, developed at major POTS treatment centers, follows a structured progression over roughly eight months. The critical principle is starting in positions where gravity isn’t working against you.
During months one through three, all cardio exercise is done lying down or seated: recumbent bikes, rowing machines, swimming, or seated steppers. Month four introduces an upright stationary bike. By month five, you can try an elliptical (without arm motion at first) or treadmill walking on a flat surface. Months six through eight add more challenge, including incline walking, jogging, and eventually high-intensity interval training.
Strength training runs alongside the cardio work in sessions of 20 to 30 minutes. Every harder workout day is followed by a lighter recovery session, and warm-ups and cool-downs are never skipped. Jumping straight into upright exercise too early typically makes symptoms worse, which is why the gradual progression matters so much.
Medications
When lifestyle changes aren’t enough, several types of medication can help. Some work by slowing the heart rate directly, making the racing-heart sensation less severe. Others help the body retain fluid or tighten blood vessels to keep blood from pooling in the legs. Treatment is usually tailored to whichever symptoms are most disabling, and it often takes some trial and error to find the right combination.
Recovery Outlook
Post-COVID POTS does improve for most people. A case series study found that 94% of patients saw meaningful improvement within about 159 days (roughly five months) of starting treatment. Heart rate responses improved significantly, and the proportion of patients able to continue working or attending school rose from about 31% to 69% over the follow-up period.
That said, improvement doesn’t always mean complete resolution. Some people recover fully, especially those who commit to the structured exercise program and dietary changes. Others see their symptoms become manageable but not disappear entirely. The trajectory varies, but the general trend for post-viral POTS is toward gradual improvement rather than permanence.