POTS vs Orthostatic Hypotension: How the Criteria Differ and Can You Have Both?

How Do the POTS and Orthostatic Hypotension Criteria Differ?

Both come from the same stand, either a tilt table test or an active stand test, and each one is read from a different line. Orthostatic hypotension (OH) is read from blood pressure. The consensus definition from the American Autonomic Society and the American Academy of Neurology, as quoted by Gibbons, 2017, is "a sustained reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg, or both, within 3 min of standing or head-up tilt to at least 60° ...".

POTS is read from heart rate. The 2021 European consensus statement on tilt testing (Thijs, Brignole et al., 2021) sets the line at a sustained heart rate increase of more than 30 bpm, or to above 120 bpm, within 10 minutes of standing, and more than 40 bpm for ages 12 to 19. Other guidelines write the same line as 30 bpm or more. Blood pressure can fall during a POTS test only as long as the fall doesn't meet OH criteria. The number alone doesn't make the diagnosis, because POTS "requires symptoms of orthostatic intolerance and the documentation of an exaggerated postural tachycardia" on a tilt or an active stand (Thijs, Brignole et al., 2021).

That tilt consensus adds 2 rules for OH. People whose blood pressure is high lying down need a systolic fall of at least 30 mmHg to count as OH. A brief fall of more than 40 systolic or 20 diastolic in the first 15 seconds of standing is called initial OH, and it passes on its own within that window (Thijs, Brignole et al., 2021).

Measure	POTS	Orthostatic hypotension	Delayed OH
Line that's read	Heart rate	Blood pressure	Blood pressure
Threshold	Sustained rise of more than 30 bpm, or to above 120 bpm	Sustained fall of at least 20 mmHg systolic or 10 mmHg diastolic	Sustained fall of at least 20 mmHg systolic or 10 mmHg diastolic
If lying-down pressure is high	No separate line listed	Systolic fall of at least 30 mmHg	Systolic fall of at least 30 mmHg
Time window	Within 10 minutes of standing	Within 3 minutes of standing or tilt to at least 60°	After 3 minutes of standing
Blood pressure rule	Any fall stays short of OH criteria	The fall is the finding	The fall is the finding
Ages 12 to 19	Rise of more than 40 bpm	No separate line listed	No separate line listed
Also required	Symptoms of orthostatic intolerance	Not part of the definition	A tilt of up to 40 minutes to catch it (Thijs, Brignole et al., 2021)
Source	Thijs, Brignole et al., 2021	Gibbons, 2017; Thijs, Brignole et al., 2021	Thijs, Brignole et al., 2021

Both results sit under orthostatic intolerance, the umbrella term for symptoms that start when you stand and ease when you lie down, and that tilt consensus treats OH as one of its causes (Thijs, Brignole et al., 2021). Our guide to orthostatic intolerance covers the broad term and its types.

Our team reads the 2 results as 2 outcomes of the same rescue. When you stand, blood pressure has to hold to keep blood reaching the brain, and the heart rate rises to help. In POTS, the rescue holds blood pressure. In the clinic's view, brain blood flow can still fall more than normal, which a standard tilt doesn't measure. In orthostatic hypotension, the rescue falls short and pressure itself falls.

Why Does the Heart Rate Rise in POTS?

In the clinic's view, blood pressure comes first. When you stand, the heart rate should come up alongside blood pressure and pull it back up. When the heart rate pulls pressure back to baseline, that's what POTS looks like on a tilt. A rising heart rate tells our team the reflexes are working: they're sensing the drop and holding blood pressure in range. The high heart rate is the compensation, so our team asks why the body needs that much of it.

The 30 bpm line has limits of its own, which our page on POTS vs OCHOS covers. For how POTS is split by mechanism, see the 3 types of POTS.

POTS Orthostatic hypotension

Replay

Can You Have POTS and Orthostatic Hypotension at the Same Time?

In a 2024 video, our team explains its position that you can't carry both diagnoses at once. One of the criteria for POTS is that there's no orthostatic hypotension. If the heart rate pulls blood pressure back to baseline, the result is POTS, and if blood pressure falls past the line anyway, the result is OH.

That tilt consensus writes that rule into the POTS definition, which allows a blood pressure fall only when it doesn't meet OH criteria (Thijs, Brignole et al., 2021). We found no passage in either consensus paper that addresses someone who shows OH on one test and POTS on another. If one test shows OH and another shows POTS, each label describes that day's stand.

Some patients still arrive with both on their chart. One case that came to the clinic had been diagnosed at a hospital with both, and it wasn't the first time our team had seen it. In one sense the labels are semantics. They still matter, because the right name steers everyone toward the right answer: did the heart rate hold blood pressure, or did pressure fall anyway?

What Does Orthostatic Hypotension Look Like When the Heart Rate Does Rise?

Our guide to orthostatic intolerance covers the 3 heart rate patterns our team sees in OH. The one the clinic sees most often, a heart rate that rises without bringing blood pressure back, is the one most easily mistaken for POTS, because the heart rate climbs in both. What separates them is whether blood pressure held. When the heart rate rises less than half a beat per minute for every point of systolic pressure lost, that tilt consensus says that points to neurogenic OH (Thijs, Brignole et al., 2021).

In the same video, our team described a patient who developed small fiber neuropathy after a viral infection, on the left side, in the feet and hands. The heart rate rose and couldn't hold blood pressure, and the Doppler during the tilt showed blood flow to the brain falling. Our team's treatment target was the small fiber neuropathy, with the goal of letting the legs constrict their blood vessels again and hold pressure on standing. This is one case, and it shows the reasoning without predicting results for anyone else. For how blood settles in the legs, hands and feet, see blood pooling and POTS, and for low brain blood flow on standing as a finding of its own, see OCHOS (orthostatic cerebral hypoperfusion syndrome).

What Is Delayed Orthostatic Hypotension, and Can It Look Like POTS?

Delayed orthostatic hypotension is a sustained fall of at least 20 mmHg systolic or 10 mmHg diastolic that comes after the first 3 minutes of standing, and that tilt consensus lists a tilt of up to 40 minutes to catch it (Thijs, Brignole et al., 2021). The POTS criteria "require a head-up tilt period of 10 min," and the same consensus says that "if other causes of orthostatic intolerance are considered (notably vasovagal presyncope or delayed OH), a longer head-up tilt is needed to establish a diagnosis." A tilt that stops early can miss a fall that comes later, so the length of the tilt decides what it can catch. A stand can show a POTS-range heart rate rise in the first 10 minutes and a blood pressure fall later. That tilt consensus notes that delayed OH "often occurs after 10 min of passive standing" (Thijs, Brignole et al., 2021), so a 10-minute tilt can label that person POTS.

The clinic adds Doppler ultrasound and end-tidal capnography to the standard tilt lines, to see whether blood flow through the brain's arteries keeps up when blood pressure dips. Our tilt table test guide covers both, along with how long the test takes. If the main complaint is a head that hurts on standing, see headache when standing.

Which Is Worse, POTS or Orthostatic Hypotension?

Neither label ranks how sick someone is. In OH, pressure itself falls, and people with OH can faint or black out as it does. If the main symptom is your vision going dark, see Why does my vision go black when I stand up?. In POTS, the heart rate keeps blood pressure up, though in the clinic's view brain blood flow can still fall more than it should, and the racing heart brings symptoms of its own. Either way the open question is what's keeping the system from holding blood flow on its own, and that's what our team tests for.

Medications can help and can give some room to work, and they have a ceiling, because they hold the system up artificially rather than letting it do more on its own. Our team doesn't ask people to come off existing medications right away, and any change is your prescriber's call.

When a stand test shows a racing heart, a falling pressure or both labels on one chart, our team tests how brain blood flow, breathing and heart rate respond when you stand, to find which part of the system is carrying the most.

POTS vs Orthostatic Hypotension: FAQ