f you have been diagnosed with POTS, you have likely been told that your heart rate rises too much when you stand.
That is technically correct.
But it is also incomplete.
Postural Orthostatic Tachycardia Syndrome is not simply a heart rate issue. It is a nervous system regulation disorder. The rise in heart rate is a symptom of something deeper happening in your autonomic system.
When you understand that, the entire picture shifts.
What Is Actually Happening in
POTS
POTS is diagnosed when heart rate increases by thirty beats per minute or more within ten minutes of standing, without a significant drop in blood pressure. This is often identified using an active stand test or tilt table test.
However, your heart does not decide on its own to accelerate.
Your brain does.
The autonomic nervous system, controlled primarily by centres in the brainstem and connected networks throughout the brain, regulates:
• Heart rate
• Blood vessel tone
• Blood pressure
• Breathing
• Temperature regulation
• Digestion
• Energy distribution
• Stress responses
When this system becomes dysregulated, your body struggles to adapt to upright posture.
Standing becomes a neurological stressor.
Why Heart Rate Rises So Quickly
When you stand, gravity pulls blood toward the lower body. In a well regulated system, blood vessels constrict and heart rate adjusts slightly to maintain stable blood flow to the brain.
In POTS, this coordination is inefficient.
The brain receives signals that circulation is insufficient. It responds by increasing heart rate aggressively to compensate. The response is not random. It is protective.
Your nervous system is trying to maintain cerebral perfusion.
The tachycardia is a strategy, not the root problem.
POTS Is About Regulation
I often explain to patients that POTS is a regulation issue.
Your system is either over responding or responding inefficiently to posture and sensory input.
This involves communication between:
• Brainstem autonomic centres
• Vestibular system
• Cerebellum
• Cortex
• Peripheral vascular control
If these systems are not integrating smoothly, symptoms emerge.
This is why patients experience far more than a racing heart.
Common Symptoms Beyond Heart Rate
People with POTS frequently report:
• Brain fog
• Dizziness
• Fatigue
• Exercise intolerance
• Temperature sensitivity
• Digestive disturbance
• Headaches
• Internal shakiness
• Anxiety like sensations
These are all regulated through the autonomic nervous system.
When regulation is unstable, multiple systems are affected.
Why Simply Slowing the Heart Is Not Enough
If we focus only on suppressing heart rate, we miss the larger picture.
Your body increased heart rate for a reason.
The more productive question is this:
Why is your nervous system struggling to regulate posture and circulation efficiently?
When we focus on improving coordination within the nervous system, the compensatory heart rate response often becomes less extreme.
My Neurological Perspective
In my work, I assess how your nervous system is processing sensory information, integrating balance input and coordinating autonomic responses.
I look at:
• Vestibular integration
• Postural reflexes
• Oculomotor control
• Autonomic balance
• Sensorimotor integration
The goal is to improve regulation at the neurological level.
When communication between brain centres becomes more efficient, the system no longer needs to overcompensate.
This is not about forcing adaptation. It is about guiding it.
Why POTS Is Increasing
There has been a noticeable increase in POTS presentations in recent years.
Common triggers include:
• Viral infections including covid
• Concussion
• Prolonged stress
• Immune activation
• Hormonal changes
• Deconditioning after illness
In many cases, a stressor disrupts autonomic balance and the system does not fully recalibrate.
The nervous system remains in a protective state.
Understanding this allows us to approach recovery more intelligently.
Can Regulation Improve
Yes.
The nervous system is adaptive. With the right input, it can reorganise and become more efficient.
Improvement does not come from pushing through symptoms. It comes from precise, progressive stimulation and structured pacing.
As regulation improves, many patients report better upright tolerance, clearer thinking and more stable energy.
If You Are Living with POTS
If you feel that your diagnosis explained the label but not the mechanism, you are not alone.
POTS is more than a heart rate condition.
It is a nervous system regulation challenge.
If you are looking for support in Melbourne, or online across Australia and worldwide, I offer neurological consultations focused on restoring regulation and improving resilience.
You can book a session and begin addressing the system behind the symptoms.
Research Articles
Raj S R. Postural Tachycardia Syndrome. Circulation. 2013;127:2336 to 2342.
Sheldon R S et al. Heart Rhythm Society Expert Consensus Statement on Postural Tachycardia Syndrome. Heart Rhythm. 2015;12:e41 to e63.
Arnold A C et al. Postural Tachycardia Syndrome Mechanisms and Management. Journal of the American College of Cardiology. 2018;72:1883 to 1896.
Vernino S et al. Autonomic Disorders. Continuum. 2020;26:44 to 68.
Freeman R et al. Consensus Statement on the Definition of Orthostatic Hypotension and Related Disorders. Clinical Autonomic Research. 2011;21:69 to 72.
