POTS (Postural Orthostatic Tachycardia Syndrome): When Your Blood Pressure and Pulse Go Haywire

Long COVID can be thought of as tripping a circuit breaker in the brain—specifically in a small but powerful control center called the hypothalamus. This structure plays a crucial role in regulating three key functions:

1. Sleep
2. Hormone balance
3. Autonomic function, including blood pressure and heart rate

Research has shown that Long COVID disrupts all three of these functions. In this article, I'll focus on the third—how Long COVID affects blood pressure and heart rate regulation, leading to a condition known as POTS (Postural Orthostatic Tachycardia Syndrome).

Another Poorly Understood Condition

Low blood pressure or difficulty regulating your heart rate can sometimes cause lightheadedness when standing, a racing heartbeat, or brain fog. These symptoms often point to POTS (Postural Orthostatic Tachycardia Syndrome). Unlike chronic fatigue syndrome, which is sometimes dismissed as a psychological issue, university medical centers recognize POTS as a legitimate physical condition. However, many doctors are unfamiliar with it and may not consider it as a diagnosis. Because of this, you may need to bring it up yourself and guide them through the discussion.

Fortunately, more doctors now understand that a tilt table test isn’t always necessary to diagnose POTS. This test is not only expensive (often not covered by insurance) but also unreliable and can leave patients feeling unwell for days. Instead, I recommend two simple at-home tests, which I’ll describe later in this article. Increasingly, experts are supporting this approach.

What's Going On?

If you think about it, we’re basically big bags of water. When we stand up, gravity pulls our blood down into our legs. For most four-legged animals, this isn’t a problem since they stay horizontal. But for humans, standing upright meant our bodies had to develop a way to keep blood circulating properly.

That job falls to the autonomic nervous system, which helps maintain balance between adrenaline (which revs things up) and calming signals. This system regulates essential functions like blood pressure, heart rate, digestion, breathing, urination, and even sexual arousal.

In many people with Long COVID, this system seems to get stuck in overdrive, leaning too heavily on adrenaline. The result? A body that feels like it’s constantly revving its engine in neutral—racing at times, then suddenly crashing.

That’s why you might not just feel a fast heartbeat, but also a pounding one. Digestion can become unpredictable, and libido may take a hit as well.

As frustrating as these symptoms are, an even bigger problem occurs when you stand up. Blood pools in your legs, and your heart races to compensate. But if it can’t keep up, your brain doesn’t get enough circulation—leading to dizziness and brain fog.

Dehydration makes everything worse. Long COVID, along with conditions like chronic fatigue syndrome (CFS) and fibromyalgia, has been linked to lower levels of adrenal stress hormones and antidiuretic hormone (ADH)—which is supposed to help your body retain water. Without enough ADH, you may find yourself constantly thirsty and peeing more than usual, leaving you depleted of both salt and fluids.

Does this sound familiar? The good news is that understanding what’s happening gives you the power to take action!

How to Make the Diagnosis

You can try two simple tests at home, and I recommend doing both. If either test is positive—especially if your symptoms match—you can take steps to manage the condition yourself. Plus, once you bring it to your doctor’s attention, they can help guide your treatment.

Traditionally, the standard way to confirm this diagnosis was the tilt-table test. In this procedure, you’re strapped to a table and gradually tilted upright to see if you faint. However, many experts now question its usefulness, noting that it’s expensive, often not covered by insurance, and can leave patients feeling worse for days.

The good news? A simple questionnaire, shown below, was found to be just as reliable as the tilt-table test in a study published in the Mayo Clinic Proceedings.

Even better, treatment with the S.H.I.N.E.® protocol can help not only with POTS but also with chronic fatigue syndrome (CFS) and fibromyalgia (FMS).

For those who want a deep dive into orthostatic intolerance, I highly recommend downloading the PDF General Information Brochure on Orthostatic Intolerance and Its Treatment by Dr. Peter Rowe, a leading researcher at Johns Hopkins and one of my personal favorites in this field.

Orthostatic Intolerance Quiz

The short quiz below, featured in the Mayo Clinic Proceedings, is a reliable screening tool for detecting orthostatic intolerance.

Self-Report Orthostatic Grading Scale¹

Orthostatic symptoms include worsening dizziness, fatigue, racing heart, or brain fog when standing. Circle 0–4 below as best applies to you.

A. Frequency of orthostatic symptoms:

0. I never or rarely experience orthostatic symptoms when I stand up.
1. I sometimes experience orthostatic symptoms when I stand up.
2. I often experience orthostatic symptoms when I stand up.
3. I usually experience orthostatic symptoms when I stand up.
4. I always experience orthostatic symptoms when I stand up.

B. Severity of orthostatic symptoms:

0. I do not experience orthostatic symptoms when I stand up.
1. I experience mild orthostatic symptoms when I stand up.
2. I experience moderate orthostatic symptoms when I stand up and sometimes have to sit back down for relief.
3. I experience severe orthostatic symptoms when I stand up and frequently have to sit back down for relief.
4. I experience severe orthostatic symptoms when I stand up and regularly faint if I do not sit back down.

_____ Total Score

Scores of 9 or higher suggest orthostatic intolerance. In Long COVID, a score of seven or higher is suggestive.

The Second Test: The 10-Minute Pulse Test

Simple At-Home Test for Orthostatic Intolerance

1. Prepare: On the first day, minimize your salt intake. The next day, follow these steps to check your heart rate and blood pressure (if possible).

2. Step 1 – Lying Down: Lie flat on your back and rest quietly for 10 minutes. Then, measure your pulse (and blood pressure, if you can).

3. Step 2 – Standing Up: Stand still without leaning or walking around. Check your pulse (and blood pressure) every two minutes for the next 10 minutes.

Interpreting Your Results:

• If heart rate in those with CFS/FMS/Long COVID increases by 15 beats per minute (bpm) or more at any point during the 10-minute standing period, this suggests orthostatic intolerance.
• If your heart rate jumps by 30 bpm or more, this confirms the diagnosis.
• Blood pressure readings can provide additional insight, especially if you’ve been unwell for over five years. A drop of more than 10 points in systolic blood pressure (the top number) may also indicate orthostatic intolerance.

While monitoring blood pressure is useful, your pulse rate is the most important factor in this test.

Key Treatments for POTS

Simple Treatments to Improve Function

These easy-to-implement treatments can significantly improve symptoms, and they work well together. The first four can be started right away, while the rest require a prescription. It’s best to begin with the first four and add prescription treatments as needed, with your doctor’s guidance.

1. Increase Salt and Water Intake

Drinking more water is essential, but people with this condition also need extra salt. Some even find it helpful to place sea salt crystals under their tongue. If you notice improvement, it means your body was craving salt. Restricting salt intake can make symptoms worse, leading to a crash.

2. Wear Compression Socks

Many people see remarkable improvement just by wearing medium-pressure (20–30 mmHg) compression stockings. Thigh-high options are ideal, but knee-high versions can still help. Wear them during the day when active (not while lying down for long periods). For additional support, some people benefit from abdominal compression (e.g., a corset or girdle), though it’s usually not necessary.

3. Support Adrenal Function

Healthy adrenal function helps the body retain salt and water. Some individuals benefit from low-dose prescription hydrocortisone (never exceeding 20 mg daily, which is roughly equivalent to 4 mg of prednisone). Additionally, natural adrenal support supplements like Adrenaplex can be highly effective in optimizing adrenal health.

4. Adjust Your Diet

Many find relief by eliminating gluten and dairy from their diet. This approach has been shown to help with CFS, fibromyalgia (FMS), and Long COVID. A 4–6 week trial will indicate whether these changes benefit you.

Medications for POTS: Where to Start

These medications can help manage POTS symptoms by targeting different aspects of the autonomic nervous system. I typically start with the following:

1. Boosting Sympathetic (Adrenaline) Tone

Midodrine (ProAmatine) can help improve blood circulation and reduce dizziness, but it takes about six weeks to show full effects.

• Dosage: 2.5–10 mg twice daily (morning and early afternoon).
• Important Notes:
  • Avoid taking it after 5:00 p.m. or when lying down, as it can raise blood pressure too much.
  • If blood pressure consistently exceeds 150/88 mmHg or if shakiness occurs, lower the dose or stop.
  • In some cases, the dose can be increased to 10 mg three times daily, with the last dose no later than 4:00 p.m.
  • Check blood pressure after 1–2 weeks to ensure it stays within a safe range.

2. Supporting Water Retention & Blood Volume

Desmopressin (DDAVP) – "Anti-Peeing Hormone"

This medication mimics the body's antidiuretic hormone (ADH), which helps retain water. In Long COVID and CFS/FMS, ADH levels are often low, making it difficult for the body to hold onto fluids—like trying to keep water in a bucket full of holes.

• Dosage: 0.1 mg once or twice in the morning (may take six weeks to see results).
• If frequent nighttime urination is an issue, an extra 0.1 mg at bedtime may help improve sleep.
• Monitoring: At higher doses, it can alter electrolyte balance, so occasional blood tests to check sodium levels may be necessary.

Fludrocortisone (Florinef) – "Salt & Water Retention Support"

This prescription synthetic adrenal hormone helps the body retain salt and water, which can be beneficial for POTS patients.

• Dosage: 0.1 mg daily.
• More effective in younger individuals (under 20), but can still help adults with chronic tachycardia (racing heart rate).

Note: Both DDAVP and Florinef can cause headaches in some individuals by shifting fluid balance too quickly.

• If headaches occur, pause the medication until symptoms subside.
• Then restart with a quarter of a tablet per day, slowly increasing the dose as tolerated.
• These two hormones can be used together for a synergistic effect.

3. Increasing Serotonin & Dopamine Levels

Medications that boost serotonin and dopamine can help regulate the autonomic nervous system and improve POTS symptoms.

• Options include:
  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Dextroamphetamine-based medications (Dexedrine, Adderall, Ritalin)
• Important Note: Stimulants should not exceed 20 mg per day to reduce the risk of addiction.

Other Helpful Treatments (Rarely Needed, But Sometimes Useful)

While the treatments below aren’t my first choice, they can be helpful in certain cases.

1. Beta-Blockers (Propranolol, Atenolol)

Some doctors prescribe beta-blockers like Propranolol (Inderal) to manage POTS symptoms. While they can help, they often worsen fatigue in people with Long COVID, CFS, and FMS.

• If you find beta-blockers help you feel better, they’re worth considering.
• If using them alongside Midodrine (ProAmatine), consider Atenolol (Tenormin) 25 mg daily instead of propranolol.

2. Ivabradine (Corlanor) – A Heart Rate Controller Without Fatigue

Ivabradine is a selective sinus node blocker, meaning it slows the heart rate without causing the fatigue associated with beta-blockers.

• Effectiveness: 44% of patients who tolerated it reported a reduction in both heart rate and fatigue after six months (though benefits likely appeared much sooner).
• Dosage: Lower doses—2.5 mg once or twice daily—often work better than higher doses.
• Side effects: The most common is a temporary brightening of vision.
• Downside: At $15 per pill, cost is a major limiting factor.

3. Pyridostigmine (Mestinon) – A Last-Resort Option

This medication can help in severe, hard-to-treat cases. However, its most common side effect is diarrhea, so I usually consider it only for patients who also struggle with constipation.

• Effectiveness: It doesn’t help most people, but for a small group of severely ill patients, it has been life-changing.
• Why? Some people may have antibodies affecting acetylcholine, a brain chemical involved in autonomic function, which could be triggering their CFS/FMS symptoms.

References:

¹Christine Schrezenmaier, Jade A. Gehrking, Stacy M. Hines, Phillip A. Low, et al., “Evaluation of Orthostatic Hypotension: Relationship of a New Self-Report Instrument to Laboratory-Based Measures,” Mayo Clinic Proceedings 80, no. 3 (March 2005): 330–334, https://doi.org/10.4065/80.3.330.