When diagnosing POTS, doctors usually begin by ruling out other conditions that cause similar symptoms—like thyroid disorders, dehydration, poor nutrition, or anaemia. Once these are addressed, they can assess whether POTS is the underlying cause. This typically involves a series of tests to evaluate how your heart rate and blood pressure respond to changes in posture.

To establish the absence of secondary causes of symptoms the following investigations are recommended before confirming a POTS diagnosis.

• ECG
• FBE, UEC, TSH, Iron studies
• Holter monitor, echocardiogram
• 24-hour ambulatory BP

Optimal Testing Time:

At least 20 minutes is required to undertake an active standing test in a clinical setting. This takes into account the time for preparation, supine resting and active standing. To maximise the effective use of physician time, consider engagement of practice nurses to undertake standing test assessments.

Conduct testing in the morning when symptoms are typically more pronounced and patients are well-rested.

Instructions on how to undertake and interpret an Active Stand Test can be found in this video or in our information sheet here.

The Australian POTS Foundation provides an Active Stand Test Template. If you are a clinician with a high flow of patients requiring assessment, you can also contact us to request pre-printed template pads for convenience.

Preparation:

• Ask the patient to wear loose fitting, comfortable clothing.
• Verify that the patient has not taken medications that restrict heart rate. (eg: beta blockers)
• Where possible undertake the test in a fasted state.
• Remove shoes and socks to ensure that dependant acrocyanosis (red/purple changes in skin colour) can be monitored throughout the test.

Equipment:

• An electronic BP monitor (a manual BP monitor may be required to confirm low blood pressure readings).
• A pulse oximeter for constant monitoring of heart rate.
• A patient bed (ideally electric)

Active Stand Test Instructions:

• Ensure the patient has been lying at rest for at least 5 minutes prior to testing.
• Inform the patient on what the test will entail.
• Have the patient stand up from the lying position in one smooth motion.
• The patient should not walk after standing (as this promotes blood return and will skew the test result).
• For safety reasons have the patient stand with a bed behind them in case of syncope.
• Encourage the patient not to fidget, talk or move their feet throughout the test.
• Monitor and document the patient’s blood pressure and heart rate every minute for 10 minutes.
• Ask the patient if they are experiencing any of the following throughout the testing period: nausea, vision changes, dizziness, headache, light headedness.
• Objectively monitor for signs of perfuse sweating, tremulousness and dependent acrocyanosis.

Diagnostic Criteria:

• A sustained rise in heart rate of ≥30 bpm in adults (or ≥40 bpm in adolescents) within the first 10 minutes of standing. Or an absolute heart rate > 120 beats per minute.
• An absence of orthostatic hypotension, defined as a decrease in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within the first 3 minutes of standing.
• Presence of unexplained symptoms for at least 3 months

Interpretation and Considerations:

• Note that sustained orthostatic hypotension which initiates within the first three minutes of standing or tilt, is consistent with a diagnosis of ‘orthostatic hypotension’ NOT POTS.
• Note that POTS symptoms fluctuate and one negative test does not exclude a POTS diagnosis. Consider repeat home standing tests to confirm.
• Postural hypertension (a blood pressure increase in response to standing or tilt) is a hallmark feature of POTS.
• We recommend the use of the Malmo POTS Symptom survey as an adjunctive diagnostic tool. A score ≥42 should illicit high suspicion for POTS.
• Syncope may be present in POTS, however it is more common for people with POTS NOT to faint during standing test.

A tilt-table test is not required to diagnose POTS, but it may be considered if the diagnosis is unclear or if an Active Stand Test is considered unsafe

Malmö POTS Symptom Survey

• The Malmö POTS Symptom Survey is a free, validated screening tool developed by researchers in Malmö, Sweden. It is designed to help identify symptom patterns consistent with Postural Orthostatic Tachycardia Syndrome (POTS). This brief survey can support initial diagnosis and can also be used longitudinally to monitor symptom progression or response to treatment.

Active Stand Test Template

• We’ve developed an Active Stand Test template for use in clinical practice to support consistent assessment and documentation. Please contact the Australian POTS Foundation if you would like us to send you a supply of Active Stand Test template pads.

How to Undertake and Interpret the Active Stand Test

• The How to Undertake and Interpret the Active Stand Test information sheet provides health practitioners with step-by-step instructions on performing the test and guidance on interpreting results.

Joint Hypermobility Survey

• The 5-Point Hypermobility Questionnaire is a quick screening tool used to identify generalised joint hypermobility, which is common in patients with POTS and related conditions. It can be easily incorporated into routine assessment.

GP Resource Sheet

• The GP Resource Sheet is a concise reference for general practitioners summarising the presentation, diagnosis, and treatment of POTS, adapted from the recently published Community Health Pathways.

Active Stand Test Instructional Video

• The Active Stand Test Instructional Video provides a step-by-step demonstration of the protocol, supporting accurate execution and standardisation of the test.