POTS Quiz: Orthostatic Symptom Score and Home Stand Test

The heart-rate rule clinicians use

Postural orthostatic tachycardia syndrome is defined by a measurement, not by a symptom list. The 2015 Heart Rhythm Society consensus statement and the 2020 Canadian Cardiovascular Society position statement both use the same core: a sustained increase in heart rate of 30 beats per minute or more within ten minutes of moving from lying to standing in adults (40 or more in adolescents aged 12 to 19), the absence of orthostatic hypotension (a blood pressure fall of 20 mmHg systolic or 10 mmHg diastolic or more), symptoms of orthostatic intolerance that are worse upright and better lying down, and a duration of months rather than days (the statements use three to six months). Other causes of a fast heart rate on standing, such as dehydration, blood loss, anemia, an overactive thyroid, fever, prolonged bed rest and medications including stimulants, decongestants and some antidepressants, have to be excluded.

Sustained is the word that matters. A heart rate that jumps 35 beats in the first thirty seconds and settles is a normal reflex; a rise that is still there at five and ten minutes is the pattern. That is why the stand test runs for ten minutes and why a single reading from a watch does not settle the question. Formal diagnosis uses an active stand test or a head-up tilt table in a clinic, usually by a cardiologist, neurologist or autonomic specialist, with an ECG and sometimes an echocardiogram to rule out a structural cause.

A home stand test you can do: the NASA lean test

The NASA lean test is a ten-minute passive standing protocol published as a bedside alternative to tilt-table testing and used by POTS and ME/CFS clinics as a screening stand test. You need a blood pressure cuff that also reports pulse (an upper-arm cuff is best; a pulse oximeter or chest strap can supply the heart rate), a wall, a chair nearby, a way to write down numbers, and ideally a second person to take the readings. Do it in the morning, when symptoms are usually worst, before caffeine, a large meal or exercise, and not on a day you are unwell. Lie flat and still for ten minutes, then record heart rate and blood pressure twice, a minute apart, while still lying down. Those are your resting values.

Stand up and lean your upper back against the wall with your heels about six inches (15 cm) from it, arms loose at your sides, feet still, no talking, no fidgeting and no shifting your weight. Record heart rate and blood pressure at one minute and then every minute for ten minutes; if you can only take a few readings, take them at one, three, five, seven and ten minutes. Sit or lie down at once if you feel faint, and write down the time you stopped. Afterwards, subtract the resting heart rate from each standing reading. A rise of 30 beats per minute or more that is present at most readings from minute three onward, without a fall in blood pressure of 20 over 10 or more, is the pattern clinicians look for. Repeat the test on two or three different mornings, because the response varies day to day, and bring the whole log to the appointment. A home log supports the conversation; it does not replace a clinic test.

What else a stand test can show

A heart-rate rise on standing has other explanations, and the same log helps sort them. If blood pressure falls by 20 systolic or 10 diastolic or more within three minutes, the pattern is orthostatic hypotension, which is a different problem with different causes and treatments. If the resting heart rate is already above 100 lying down, the question becomes inappropriate sinus tachycardia or a cause such as thyroid disease, anemia, fever or a stimulant. If the rise disappears after a few weeks of regular fluids, salt as your clinician advises and gradual recumbent exercise, deconditioning or volume depletion were likely contributing, which is good news.

POTS also travels with other conditions. It is common after infections, including COVID-19 and mononucleosis, and in people with myalgic encephalomyelitis or chronic fatigue syndrome, joint hypermobility, mast cell activation symptoms, migraine and autoimmune disease. That is why the first appointment usually includes a complete blood count, ferritin, thyroid function, electrolytes, a morning ECG and a careful medication review, before any label is applied.

Methodology and sources

The twelve items are original. They were written to cover the domains in which orthostatic intolerance shows up in daily life, informed by the symptom domains of the COMPASS-31, the Composite Autonomic Symptom Score, whose six domains (orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder and pupillomotor) describe autonomic symptoms broadly. The COMPASS-31 is a licensed instrument and is not reproduced here; its items, response options, order and scoring are not used. These items instead ask how often a concrete situation happened in the past month (standing in a line, a hot shower, a large meal, a day upright), grouped into four domains of their own: standing and posture, circulation and temperature, meals and gut, and energy and thinking. Bladder and pupil symptoms are left out because they are less specific to POTS.

Each item is scored 0 (never), 1 (once or twice), 2 (most weeks) or 3 (most days), for a total of 0 to 36, with four domains of three items scored 0 to 9 each. The bands (0 to 6 low, 7 to 14 mild, 15 to 24 moderate, 25 to 36 high) are educational cut points that separate an occasional episode from a weekly or daily pattern. They have not been validated against a stand test, a tilt table or any diagnosis, and the heart-rate criterion quoted on the page was validated for the measurement itself, not for this questionnaire. The quiz describes how often orthostatic symptoms happened; the stand test measures whether the heart-rate pattern is present.

This is an educational screener. Light-headedness, a racing heart, fatigue and brain fog have many causes, including anxiety, dehydration, anemia, thyroid disease, medications and deconditioning, and POTS itself is a diagnosis of exclusion made by a clinician with an active stand or tilt-table test, an ECG and blood tests. Fainting with injury, fainting during exercise, chest pain, a heart rate that stays very high at rest, or new neurological symptoms are reasons to be seen promptly whatever the score.

Medical review: Medical review pending. Last updated October 8, 2026.

References

1. Sheldon RS, Grubb BP 2nd, 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;12(6):e41-e63. doi:10.1016/j.hrthm.2015.03.029
2. Raj SR, Guzman JC, Harvey P, et al. Canadian Cardiovascular Society position statement on postural orthostatic tachycardia syndrome (POTS) and related disorders of chronic orthostatic intolerance. Can J Cardiol. 2020;36(3):357-372. doi:10.1016/j.cjca.2019.12.024
3. Lee J, Vernon SD, Jeys P, et al. Hemodynamics during the 10-minute NASA Lean Test: evidence of circulatory decompensation in a subset of ME/CFS patients. J Transl Med. 2020;18(1):314. doi:10.1186/s12967-020-02481-y
4. Sletten DM, Suarez GA, Low PA, Mandrekar J, Singer W. COMPASS 31: a refined and abbreviated Composite Autonomic Symptom Score. Mayo Clin Proc. 2012;87(12):1196-1201. doi:10.1016/j.mayocp.2012.10.013
5. 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, Part 1. Auton Neurosci. 2021;235:102828. doi:10.1016/j.autneu.2021.102828