POTS (postural orthostatic tachycardia syndrome) - Wokingham, Berkshire

On this page

1. Overview
2. Symptoms
3. Causes and risk factors
4. Diagnosis
5. POTS in Chinese medicine
6. Acupuncture for POTS
7. Chinese herbal medicine for POTS
8. Moxibustion for POTS
9. Self-care
10. Treatment at my clinic
11. Frequently asked questions
12. References

1. What is POTS?

Postural orthostatic tachycardia syndrome (POTS) is a form of dysautonomia — a disorder of the autonomic nervous system — defined by a sustained, exaggerated rise in heart rate of at least 30 beats per minute (40 in adolescents) within ten minutes of standing, in the absence of a meaningful drop in blood pressure, accompanied by symptoms of orthostatic intolerance. The disorder predominantly affects women aged 15 to 50 and is estimated to affect around 1–3 million people in the United States and a comparable proportion of the UK population, with cases rising sharply since the COVID-19 pandemic.

POTS is a chronic, disabling condition that is frequently misdiagnosed or dismissed as anxiety or panic disorder, with the average time to diagnosis exceeding four years. Conventional management focuses on symptomatic measures — salt and fluid loading, compression garments, beta-blockers, ivabradine and midodrine — but no single pharmaceutical treatment is curative and many patients experience persistent symptoms despite optimal medical management. Traditional Chinese medicine (TCM), including acupuncture and Chinese herbal medicine, addresses the underlying autonomic dysregulation and the deeper patterns of Qi, Blood, Heart and Kidney deficiency that drive POTS, rather than suppressing individual symptoms. Emerging clinical research and decades of TCM clinical experience support the use of acupuncture and Chinese herbs for reducing orthostatic intolerance, palpitations, dizziness and fatigue.

2. Symptoms of POTS

POTS produces a cluster of symptoms that worsen on standing (or sometimes sitting) and improve on lying flat. The symptom picture is broad, often baffles patients and physicians, and overlaps significantly with chronic fatigue syndrome, long COVID and other dysautonomias. Core and associated symptoms include:

1. Rapid heart rate on standing — a sustained increase of 30 bpm (40 in adolescents) within ten minutes of becoming upright, often perceived as palpitations, pounding, or a sense that the heart is racing or skipping
2. Lightheadedness and dizziness — particularly on standing, in hot environments, after meals or after standing still for long periods (queuing, showering, cooking)
3. Pre-syncope and syncope — near-fainting or actual fainting episodes, sometimes provoked by standing, hot showers, emotional stress or seeing blood
4. Profound fatigue — out of proportion to activity, often with post-exertional symptom flares similar to those seen in CFS/ME
5. Brain fog and cognitive impairment — difficulty concentrating, word-finding, memory lapses, slowed thinking; often worse when upright and better when lying down
6. Exercise intolerance — inability to sustain physical activity that was previously tolerable; deconditioning develops quickly and worsens symptoms further
7. Gastrointestinal symptoms — nausea, bloating, early satiety, constipation or diarrhoea, and the IBS-overlap features seen in many dysautonomia patients
8. Temperature dysregulation — cold extremities, mottled or purple-blue legs and feet on standing (acrocyanosis), heat intolerance and difficulty sweating normally
9. Sleep disturbance — difficulty falling asleep, unrefreshing sleep, vivid dreams and frequent waking; many patients are tired during the day yet wired at night
10. Headaches and migraine — particularly on standing and in the morning, often with a throbbing or pressure quality
11. Tremor, shakiness and adrenergic symptoms — particularly in the hyperadrenergic POTS subtype
12. Anxiety and panic-like sensations — secondary to the autonomic surge, not a primary psychiatric disorder; POTS is frequently misdiagnosed as anxiety disorder

3. Causes and risk factors of POTS

POTS is not a single disease but a final common pathway reached through several different mechanisms. Current research recognises at least three clinical subtypes — hyperadrenergic POTS (excessive sympathetic activity), neuropathic POTS (partial autonomic neuropathy with peripheral pooling of blood) and hypovolaemic POTS (chronic reduction in circulating blood volume) — though many patients show features of more than one. Recognised triggers and risk factors include:

1. Post-viral onset — the most common identifiable trigger. POTS frequently develops in the weeks or months after a viral illness, particularly Epstein-Barr virus (glandular fever), SARS-CoV-2 (COVID-19), enteroviruses and influenza. The rise in POTS cases since 2020 has paralleled the recognition of long COVID
2. Joint hypermobility and Ehlers-Danlos syndrome — up to half of POTS patients have hypermobile joints, and POTS is strongly associated with hypermobile Ehlers-Danlos syndrome (hEDS), reflecting connective tissue laxity in blood vessels and the autonomic nervous system
3. Autoimmune dysfunction — autoantibodies against adrenergic and muscarinic receptors have been identified in a subset of POTS patients, suggesting an autoimmune mechanism in at least some cases
4. Female sex and hormonal factors — POTS affects women approximately five times more often than men, and symptoms frequently fluctuate with the menstrual cycle and worsen in the second half of pregnancy
5. Surgery, trauma or pregnancy as triggers — abdominal surgery, major trauma and pregnancy can precipitate POTS in susceptible individuals
6. Mast cell activation syndrome (MCAS) — a significant subset of POTS patients also have MCAS, with allergic-type symptoms, flushing, food sensitivities and chemical reactions
7. Prolonged immobility or deconditioning — bedrest after illness or surgery can trigger or worsen POTS; reconditioning is challenging because exertion provokes symptoms
8. Sustained stress and nervous system overload — chronic stress, trauma and burn-out are frequently reported preceding POTS onset and contribute to the dysautonomic state

4. Diagnosis

POTS is a clinical diagnosis confirmed by a defined heart rate response to standing or head-up tilt, in the absence of other explanatory conditions. Diagnosis requires:

1. An active stand test or head-up tilt-table test — the patient’s heart rate and blood pressure are measured while lying flat, then repeated at 1, 3, 5 and 10 minutes after standing. A sustained heart rate increase of at least 30 bpm in adults (40 in adolescents) within 10 minutes, with symptoms of orthostatic intolerance and without sustained orthostatic hypotension, supports the diagnosis
2. Symptom duration of at least three months — transient orthostatic tachycardia after viral illness or dehydration does not by itself constitute POTS
3. Exclusion of other causes — investigations to exclude thyroid disease (TSH, T4), anaemia (full blood count, ferritin), diabetes (fasting glucose, HbA1c), structural heart disease (ECG, echocardiogram), phaeochromocytoma in selected cases (plasma metanephrines), Addison’s disease (cortisol) and other causes of orthostatic symptoms
4. Subtype identification — once the diagnosis is made, identifying the predominant mechanism (hyperadrenergic, neuropathic, hypovolaemic, or mixed) guides treatment. Hyperadrenergic POTS typically responds to beta-blockers and ivabradine; neuropathic POTS may respond to compression garments and midodrine; hypovolaemic POTS responds to fluid and salt loading
5. Investigation of associated conditions — assessment for joint hypermobility, Ehlers-Danlos features, mast cell activation, autoimmune markers and post-viral overlap, as these affect treatment planning

5. POTS in Chinese medicine

In traditional Chinese medicine, the symptoms that define POTS correspond to several overlapping patterns of imbalance affecting the Heart, Spleen, Kidney and Liver. TCM theory is well placed to address POTS because it considers the heartbeat, blood pressure regulation, vascular tone, postural stability and emotional state as a single integrated system — the same system that modern medicine calls the autonomic nervous system. Common TCM patterns seen in POTS include:

1. Heart and Spleen Qi deficiency (Xin Pi Liang Xu) — the most common pattern. The Spleen produces and contains the Blood; the Heart governs the circulation of Blood. When both are deficient, the patient experiences palpitations on exertion, fatigue, dizziness on standing, poor memory, brain fog, pale complexion and a thin pulse. Treatment tonifies Heart and Spleen Qi with formulae such as Gui Pi Tang
2. Heart Qi and Yang deficiency — when the deficiency progresses, Yang weakens too. The patient feels cold, has marked palpitations on exertion, low blood pressure, cold extremities, breathlessness and a deep weak pulse. Treatment warms and tonifies Heart Yang with formulae built around Gui Zhi Gan Cao Long Gu Mu Li Tang or Zhi Gan Cao Tang
3. Kidney Yang deficiency failing to anchor Heart Yang — Kidney Yang in TCM is the foundational warming and stabilising fire of the whole body. When it fails, Heart Yang loses its support; the patient feels the “floating” quality so characteristic of POTS — heart racing on standing, lightheadedness, sensation of being “unanchored”. Treatment warms Kidney Yang with formulae such as Jin Gui Shen Qi Wan
4. Heart Yin and Blood deficiency with disturbed Shen — in patients with marked palpitations, restless sleep, vivid dreams, night sweats, anxious quality, dry mouth, a red tongue with little coating and a thin rapid pulse. The Heart-Mind is insufficiently nourished and easily destabilised. Treatment nourishes Heart Yin and Blood with formulae such as Tian Wang Bu Xin Dan
5. Liver Yang rising with underlying Yin deficiency — common in hyperadrenergic POTS. The patient describes surges of heat, tremor, sweating, anxiety, irritability, headaches and palpitations that come in waves. Treatment subdues Liver Yang and nourishes the underlying Yin with formulae such as Tian Ma Gou Teng Yin
6. Phlegm and Damp obstruction — in patients whose POTS is post-viral or accompanies mould exposure, with heavy fatigue, brain fog, chest oppression, nausea and a thick greasy tongue coating. Treatment resolves Damp and transforms Phlegm with formulae such as Wen Dan Tang

6. Acupuncture for POTS

Acupuncture addresses POTS through several well-documented physiological mechanisms. It directly modulates the autonomic nervous system, increasing parasympathetic (vagal) tone and reducing sympathetic over-activity; it normalises baroreceptor function and reflex blood pressure regulation; it improves heart-rate variability (a key marker of autonomic balance); and it reduces the systemic inflammation, anxiety and sleep disturbance that perpetuate dysautonomia. Specifically, acupuncture for POTS works by:

1. Stimulating the vagus nerve through points such as PC 6 (Neiguan), HT 7 (Shenmen) and CV 17 (Tanzhong), which directly increases parasympathetic activity and reduces the exaggerated tachycardia of POTS
2. Regulating the hypothalamic-pituitary-adrenal axis and reducing the chronically elevated noradrenaline levels seen in hyperadrenergic POTS
3. Improving baroreflex sensitivity and vascular tone, helping the body to redistribute blood appropriately on standing
4. Reducing systemic inflammation, which is often elevated in post-viral POTS
5. Calming the Shen (Heart-Mind), which reduces the anxious adrenergic quality and improves sleep
6. Tonifying Qi and Blood, the underlying TCM deficiencies, with points such as ST 36 (Zusanli), SP 6 (Sanyinjiao), BL 15 (Xinshu, the Heart back-shu point) and BL 23 (Shenshu, the Kidney back-shu point)
7. Reducing pain, headache and the muscle tension that often accompany POTS

Research evidence

Direct randomised controlled trial evidence for acupuncture in POTS is still emerging but the underlying mechanisms are well established. A 2017 systematic review and meta-analysis by Zhao et al., published in Acupuncture in Medicine, found that acupuncture significantly improves heart-rate variability in patients with various autonomic disorders, with effect sizes comparable to or greater than those reported for ivabradine in POTS. A 2020 randomised trial by Zhang et al. found that acupuncture combined with conventional treatment produced greater improvements in orthostatic tolerance, fatigue and quality of life than conventional treatment alone in patients with orthostatic intolerance. A growing body of research on acupuncture for long COVID — the largest current cohort of new POTS patients — reports significant improvements in orthostatic symptoms, fatigue and cognitive function. Research on the closely related conditions of CFS/ME and dysautonomia consistently supports acupuncture as an effective adjunct.

Watch the video below which explains how acupuncture relieves pain:

7. Chinese herbal medicine for POTS

Chinese herbal medicine is an essential part of POTS treatment within TCM because the underlying pattern is one of constitutional deficiency that needs continuous, day-by-day support. A tailored herbal formula taken daily provides ongoing tonification, autonomic regulation and Shen-calming between acupuncture sessions. Herbal treatment is prescribed individually based on the TCM pattern. Commonly used formulae for POTS include:

1. Gui Pi Tang (Restore the Spleen Decoction) — the foundational formula for Heart and Spleen Qi/Blood deficiency. Contains Huang Qi (Astragalus), Dang Shen (Codonopsis), Bai Zhu (Atractylodes) and Suan Zao Ren (Sour Jujube). Tonifies Qi and Blood, calms the Heart-Mind, and gradually rebuilds the deficient reserves driving POTS
2. Tian Wang Bu Xin Dan (Emperor of Heaven’s Special Pill to Tonify the Heart) — for Heart Yin and Blood deficiency presenting with marked palpitations, vivid dreams, night sweats and a red tongue with little coating
3. Zhi Gan Cao Tang (Honey-fried Liquorice Decoction) — the classical Shang Han Lun formula for irregular pulse, palpitations, breathlessness and Heart Qi-Yin deficiency. Frequently used where POTS is accompanied by arrhythmia features
4. Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet) — for Kidney Yang deficiency failing to anchor Heart Yang, with cold extremities, low blood pressure and a deep weak pulse
5. Sheng Mai San (Generate the Pulse Powder) — the classical formula for Qi and Yin deficiency of the Heart and Lung, with shortness of breath, palpitations on exertion, dry mouth and a weak pulse. Particularly useful in post-viral POTS where Yin has been consumed
6. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) — for sinking Qi with profound fatigue, dizziness on standing, low blood pressure and prolapse symptoms
7. Individual tonic and regulating herbs — Huang Qi (Astragalus) increases blood volume and supports vascular tone; Dang Shen (Codonopsis) gently tonifies Qi; Mai Men Dong (Ophiopogon) and Wu Wei Zi (Schisandra) nourish Yin and stabilise the Heart rhythm; Long Gu and Mu Li anchor the Shen and steady palpitations

All herbs prescribed at this clinic are pharmaceutical-grade granule extracts supplied by Sun Ten (Taiwan), ensuring consistent potency and purity. An online Chinese herbal medicine consultation is available for patients who cannot attend in person — particularly relevant for POTS patients who find travel difficult.

8. Moxibustion for POTS

Moxibustion — warming the body with smouldering moxa (dried Artemisia) over specific acupuncture points — is particularly effective for the cold-deficient subtype of POTS, where there is marked Yang deficiency, low blood pressure, cold extremities and exhaustion. Moxibustion at CV 4 (Guanyuan), CV 6 (Qihai), CV 8 (Shenque, with salt or ginger) and ST 36 (Zusanli) gently tonifies Yang, increases circulating warmth and supports autonomic function. Heat therapy with an infrared TDP lamp over the lower abdomen and lower back can be used at home between sessions and produces gradual, cumulative benefit.

9. Self-care for POTS

Self-management is central to POTS care and significantly amplifies the effect of acupuncture and herbal treatment. The following strategies are evidence-based first-line measures and underlie any TCM treatment plan:

1. Salt and fluid loading — aim for 3–10 grams of salt per day (under medical guidance) and 2–3 litres of fluid daily, prioritising the morning when blood volume is lowest. Electrolyte drinks (oral rehydration solutions) are useful
2. Compression garments — medical-grade compression stockings (20–30 mmHg, waist-high) or abdominal binders reduce blood pooling in the lower body and significantly improve orthostatic tolerance
3. Counter-pressure manoeuvres — crossing the legs, tensing the calf muscles, gripping the hands, squatting briefly before rising; these increase venous return and abort symptom flares
4. Gradual reconditioning — reclined or recumbent exercise (rowing machine, recumbent bike, swimming, mat-based exercises) is far better tolerated than upright exercise. The CHOP and Levine protocols offer structured rehabilitation programmes shown in research to improve POTS symptoms over 3–6 months. Avoid the trap of overexertion followed by collapse
5. Avoid triggers — large meals, alcohol, hot baths, prolonged standing, deconditioning and dehydration all worsen POTS. Smaller, more frequent meals and cooler showers significantly reduce post-prandial and heat-triggered symptoms
6. Sleep hygiene and head elevation — sleeping with the head of the bed raised 10–15 cm reduces overnight diuresis and helps the body retain blood volume. Consistent sleep and wake times support autonomic recovery
7. Dietary support — a whole-food diet with adequate protein, complex carbohydrates and electrolytes. Many POTS patients benefit from reducing or removing gluten and dairy (see gluten and dairy in TCM) and from avoiding raw cold foods (see why salads can be bad in TCM) which can further weaken the Spleen
8. Mind-body practices — breathwork (slow nasal breathing at around 5–6 breaths per minute), yoga nidra and gentle restorative yoga directly stimulate vagal tone and reduce sympathetic over-activity. Vigorous yoga or hot yoga, by contrast, often provokes symptoms
9. Address underlying triggers — where POTS is post-viral, support full viral recovery; where mast cell activation co-exists, address it; where mould exposure is identified, remove the environmental source (see mould exposure)

10. POTS treatment at my clinic

I treat POTS at my clinic in Wokingham, Berkshire, combining acupuncture, Chinese herbal medicine and moxibustion in a tailored programme matched to the individual’s TCM pattern and POTS subtype. Treatment is adjusted to each patient’s current functional capacity — gentler, less stimulating sessions are used in the early phase or in severely symptomatic patients to avoid provoking flares, and the intensity is gradually increased as orthostatic tolerance improves.

POTS is a condition that needs sustained treatment to produce durable change. Most patients notice some improvement in palpitations, sleep and energy within four to eight weekly sessions; meaningful, sustained improvements in orthostatic tolerance, cognitive function and exercise capacity develop over three to six months. Chinese herbal medicine taken daily between sessions is strongly recommended — it provides continuous tonification of the deeply depleted reserves that drive POTS and accelerates recovery. See the prices page for treatment costs and the online herbal consultation page for those who prefer to begin herbal treatment remotely.

11. Frequently asked questions about POTS

Can acupuncture help with POTS?

Yes. Acupuncture directly modulates the autonomic nervous system, increases vagal (parasympathetic) tone, improves heart-rate variability and reduces the exaggerated sympathetic activity that drives POTS symptoms. Research on acupuncture in autonomic dysfunction, post-viral conditions and the closely related CFS/ME consistently supports its use, and clinical experience in POTS reflects the same. Acupuncture is generally used alongside conventional measures (salt, fluids, compression, exercise) rather than instead of them.

How many acupuncture sessions are needed for POTS?

POTS is a chronic, multifactorial condition that requires a sustained course of treatment. Most patients notice initial improvements in palpitations, sleep and energy within four to eight weekly sessions. Meaningful improvements in orthostatic tolerance, cognitive function and exercise capacity typically develop over three to six months. Given the tendency of POTS to fluctuate and relapse, periodic maintenance treatment after the initial course can help sustain gains.

Is POTS the same as long COVID?

No, but they overlap significantly. POTS is a specific dysautonomia defined by a measurable heart-rate response to standing. Long COVID is the broader post-acute sequelae of SARS-CoV-2 infection. POTS has become much more common since 2020 because it is one of the most frequent manifestations of long COVID — current estimates suggest 2–14% of long COVID patients meet POTS criteria. In TCM terms, both conditions reflect post-viral depletion of Qi, Yin or Yang and respond to similar treatment principles.

Will the salt and water alone fix my POTS?

For some patients with mild hypovolaemic POTS, increased salt and fluid intake alone produces a meaningful improvement. For most, it is one helpful measure but not enough on its own. POTS is driven by autonomic, hormonal, vascular and (often) post-viral factors that require a multi-layered approach — compression, reconditioning, sleep regulation, dietary support and treatment of underlying triggers. Acupuncture and Chinese herbal medicine sit alongside these measures and accelerate recovery.

Is POTS dangerous?

POTS is rarely life-threatening and does not shorten life expectancy, but it is significantly disabling and can severely affect quality of life, school and work. Untreated POTS often deteriorates over time as patients deteriorate physically from forced rest and develop secondary depression and anxiety. Early identification and active treatment markedly improve the long-term outlook. Around 50–80% of patients improve significantly with sustained treatment.

Can Chinese herbal medicine be taken alongside POTS medications?

In most cases, yes. Chinese herbal medicine is generally compatible with the common POTS medications (beta-blockers, ivabradine, midodrine, fludrocortisone) and the two approaches address different aspects of the condition. As with any combined treatment, your full medication list is reviewed at the initial consultation and the prescription is adjusted accordingly. Patients are encouraged to keep their cardiologist or POTS specialist informed of all treatments they are receiving.

Does acupuncture worsen POTS symptoms?

Acupuncture is generally well tolerated in POTS, but in sensitive patients a session that is too stimulating or too long can briefly worsen lightheadedness or palpitations. Treatment is therefore tailored to current functional capacity — shorter sessions, fewer needles, gentler stimulation and treatment in the recumbent position in the early phase. As orthostatic tolerance improves, the intensity of treatment can be increased.

12. References

Sheldon RS, Grubb BP, Olshansky B, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015 Jun;12(6):e41–63. PMID: 25980576.

Vernino S, Bourne KM, Stiles LE, et al. Postural orthostatic tachycardia syndrome (POTS): state of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting. Auton Neurosci. 2021 Nov;235:102828. PMID: 34144933.

Blitshteyn S, Whitelaw S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients. Immunol Res. 2021 Apr;69(2):205–211. PMID: 33786700.

Bryarly M, Phillips LT, Fu Q, Vernino S, Levine BD. Postural orthostatic tachycardia syndrome: JACC Focus Seminar. J Am Coll Cardiol. 2019 Mar 19;73(10):1207–1228. PMID: 30871704.

Li QQ, Shi GX, Xu Q, Wang J, Liu CZ, Wang LP. Acupuncture effect and central autonomic regulation. Evid Based Complement Alternat Med. 2013;2013:267959. PMID: 23983778.

Prefer to be treated from home? Chinese herbal medicine online consultations are available throughout the UK and worldwide. After a full video consultation, Dr (TCM) Attilio D'Alberto formulates a bespoke herbal prescription and posts your Chinese herbs directly to your door.