Introduction

Postural Orthostatic Tachycardia Syndrome (POTS) is a condition that affects the body's ability to control blood flow. When someone with POTS stands up, their heart rate increases by at least 30 beats per minute within ten minutes without a drop in blood pressure.¹ Two of the most troubling symptoms people with POTS experience are chest pain and a racing heartbeat, also known as palpitations. These symptoms can seriously impact daily life.² The body tries to make up for poor blood circulation by making the heart beat faster, especially when blood pools in the legs. This often happens due to low blood volume or weak blood vessels.^3,4 Although chest pain in POTS usually isn't caused by heart disease, it can still feel very uncomfortable. It may be due to temporary strain on the heart, changes in how the heart works, or issues with the nervous system.⁵ These symptoms often worsen when standing and improve when lying down. Understanding what causes these heart-related symptoms is key to finding the right treatment and improving quality of life.¹

Overview of POTS

POTS mostly affects young people, particularly women, and often leads to symptoms like a racing heart and chest pain that can make daily life difficult.⁶ Most people begin to experience POTS symptoms during their teenage years or early twenties, and it is much more common in females than males. While the exact cause isn’t fully understood, POTS can sometimes be triggered by things like infection, surgery, pregnancy, or even a traumatic event.⁷ POTS happens because the part of the nervous system that controls blood flow doesn’t work as it should. When standing up, blood can pool in the legs, making it harder for blood to return to the heart.³ To make up for this, the heart beats faster to try and maintain blood flow to the brain, leading to symptoms like dizziness, fatigue, or a fast heart beat, Some people also have high levels of stress hormones (like norepinephrine) when they stand, which can make their symptoms, like palpitations or shakiness, wose.³

Palpitations in POTS occur because the body is trying to keep enough blood flowing to the brain. The fast heartbeat, often over 120 beats per minute when standing, can come with tiredness or feeling faint.¹ Chest pain can also happen, although it isn’t related to heart disease. Instead, it may be caused by temporary stress on the heart or by how the nervous system is functioning.^1,8 Unlike chest pain from a heart attack, this type of discomfort often doesn’t improve with medication like nitroglycerin. These symptoms tend to get worse when standing and feel better when lying down, which helps distinguish POTS from other heart problems or anxiety disorders.^1,9

Palpitations in POTS

One of the most troubling symptoms of POTS is palpitations, which is when your heart feels like it’s beating too fast, too hard, or skipping a beat. These episodes often happen when standing or even with light activity, and heart rates can go over 120 beats per minute. This can feel scary and overwhelming, especially since the symptoms may appear suddenly without warning.¹⁰ These palpitations happen because, when someone with POTS stands up, their body struggles to push blood back to the heart. Blood tends to pool in the legs, so the heart speeds up to keep enough blood flowing to the brain.¹¹ This extra effort can lead to tiredness, lightheadedness, and even difficulty with daily tasks or exercise.¹² The body gets overworked trying to compensate, and many people also feel anxious because they don’t know when an episode might happen.^11,12

Sometimes palpitations come with chest discomfort that isn’t caused by heart disease but instead by how the heart and nervous system are reacting. You might see small changes on heart tests like ECGs, but these aren’t the same as signs of a heart attack. The pain doesn’t usually go away with heart medications like nitroglycerin, and it can be accompanied by a feeling of nausea or "brain fog”.¹⁰

Chest pain in POTS

Chest pain in POTS can feel sharp, pressure-like, or achy and is usually felt on the left side of the chest. It can occur on its own or alongside palpitations, but it’s rarely caused by a blocked artery or a heart attack. Most of the time, this pain comes from changes in blood flow or from the heart working harder when upright. It can also be linked to muscle tension from poor posture or anxiety. Even though it’s not life-threatening, chest pain can feel scary, especially when it happens during normal daily activities. This can lead to extra stress and worry. It’s important for patients to know that this type of chest pain is common in POTS and doesn’t mean their heart is damaged.^3,7

Diagnosis 

Doctors often begin by ruling out serious heart conditions, especially when a patient reports chest pain. It’s common to run tests like ECGs, Holter monitors, or echocardiograms, and while these may show mild changes, they usually are not signs of serious heart diseases.⁵ Knowing that the heart is structurally healthy can bring reassurance to patients who may fear the worst. This reassurance is an important part of treatment, especially for those who’ve lived with symptoms for a long time without a clear diagnosis.¹³

To diagnose POTS, doctors use a tilt table test or ask you to stand while they monitor your heart rate.¹³ If your heart rate jumps by 30 beats or more within 10 minutes of standing (without your blood pressure dropping), and you’ve had symptoms like dizziness or palpitations for at least 3-6 months, POTS may be the cause.

Treatment

Treatment focuses heavily on lifestyle changes. Drinking 2-3 litres of water per day and increasing salt intake to 10-12 grams per day under medical advice can help your body hold on to fluid and improve blood circulation. Wearing compression stockings helps stop blood from pooling in your legs.¹³ Exercise programs designed for POTS, like the Levine Protocol, can improve symptoms over time.

In some cases, medications like ivabradine or propranolol (a beta-blocker) can help slow your heart rate, and midodrine may help tighten your blood vessels to reduce symptoms.¹⁴ Even with treatment, many people with POTS report that their quality of life is similar to those living with serious chronic conditions like heart failure. That’s why treatment needs to be holistic, addressing both physical symptoms and emotional well-being.¹⁵

Patient experience and quality of life

Living with POTS can have a deep impact on daily life. Many people experience chest pain and palpitations that feel frightening, even if tests show no serious heart problems.^7,16 These symptoms often come and go without warning, which can lead to anxiety and make people avoid exercise, social situations, or even leaving the house. Studies show that most people with POTS need help with basic tasks like shopping, and some even need help getting dressed or moving around.¹⁶ Even after receiving a diagnosis, it can take time to feel better, and physical functioning may still be limited. People with POTS often report quality of life scores similar to those with long-term conditions like heart failure. These effects can be especially hard on younger people, who may feel isolated from their peers and left behind in school or work.¹⁷

Support from others—whether it’s from a doctor, therapist, or another person with POTS—can make a big difference.^16,18 Counselling can help manage the anxiety that often comes with chronic symptoms and teach helpful ways to cope. Learning how to prevent flare-ups, like staying hydrated, using compression gear, and building up exercise slowly, can reduce the need for hospital visits.^3,18 Patient education is powerful: the more people who understand their condition, the more confident they feel in managing it. Support groups can also be a lifeline, helping people feel understood and less alone. Even though some people may still struggle with symptoms, especially teenagers trying to live a normal life, these types of support can help people feel more in control and hopeful about the future.^3,19

FAQs

Are symptoms like chest pain and palpitations in POTS dangerous?

Chest pain and palpitations in POTS are usually not caused by heart disease. They happen because of changes in how your body controls blood flow when standing. While they can feel scary, they’re rarely life-threatening. Still, it’s important to get evaluated by a doctor to rule out other conditions.

What can I do to manage POTS symptoms day to day?

Simple steps like drinking 2–3 litres of water daily, eating more salt (if your doctor says it’s safe), wearing compression socks, and building up exercise slowly can help reduce symptoms. Avoiding long periods of standing and heat can also make a difference.

Will I get better from POTS?

Many people with POTS see improvement over time, especially with a proper care plan. Some fully recover, while others manage symptoms long term. Getting support from doctors, therapists, or POTS communities can help you stay on track and feel more hopeful.

Summary

Postural Orthostatic Tachycardia Syndrome (POTS) can cause serious symptoms like a fast heart rate, palpitations, and chest pain—especially when standing. These symptoms aren’t usually caused by heart disease but come from how the nervous system controls blood flow. They can be frightening and interfere with daily life, work, and relationships.

Thankfully, many people feel better with lifestyle changes like drinking more water, eating more salt, wearing compression garments, and doing gentle, regular exercise. Some may also need medication to manage their symptoms. Support from a medical team, therapy, and connecting with others who have POTS can make a big difference.

While there’s no cure yet, with the right treatment and understanding, symptoms can be managed and quality of life can improve. Early diagnosis and a personalised care plan are key to getting better and feeling more in control.