Why the study?
Many patients with orthostatic intolerance experience autonomic dysfunction and functional impairment despite not meeting current POTS heart rate criteria, leading to underdiagnosis and exclusion from research.
An international expert panel developed 31 consensus statements with >90% agreement to guide the recognition, diagnosis, and management of POTS and non-POTS dysautonomia.
Clinicians should evaluate and treat symptomatic dysautonomia even without meeting POTS heart rate thresholds; leaves optimal criteria and management open for prospective trials.
BACKGROUND: Current diagnostic criteria for postural orthostatic tachycardia syndrome (POTS) require history of orthostatic intolerance and heart rate elevation of ≥30 bpm in adults or ≥40 bpm in adolescents during a 10-minute standing or a tilt table test. Many patients with orthostatic intolerance experience autonomic dysfunction and functional impairment despite not meeting the required heart rate increase. These patients remain undiagnosed, untreated and excluded from research studies. We sought to develop international multidisciplinary consensus guidance statements addressing the recognition, diagnosis, treatment, functional impact, and future directions of POTS and non-POTS dysautonomia using a modified Delphi methodology. METHODS: A multidisciplinary international expert panel of pediatric and adult specialists in POTS and dysautonomia, including patient advocacy representatives, voted on consensus statements developed through iterative expert discussion, meetings and literature review by an independent core collaborative group consisting of clinicians specializing in POTS and dysautonomia. Statements addressing pathophysiology, diagnosis, treatment, education, advocacy, and research priorities were evaluated. Consensus was predefined as ≥70% agreement. RESULTS: 31 consensus statements were evaluated by the international multidisciplinary panel of experts from 7 countries (40 contributors). All statements achieved very strong (> 90%) to unanimous (100%) consensus, with 24 of 31 statements achieving unanimous consensus. Qualitative analysis of comments highlighted need for standardized nomenclature and classification system. CONCLUSION: This international multidisciplinary consensus guidance statement addressed an unmet clinical gap by providing recommendations for recognition, diagnosis and management of POTS and non-POTS dysautonomia. Adoption of these recommendations may improve diagnostic accuracy, patient care, clinical trial inclusion, and future therapeutic development.
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Sivakoti et al. (2026) studied Postural Orthostatic Tachycardia Syndrome (POTS) and Dysautonomia (n=40). Modified Delphi methodology for consensus guidance was evaluated on Consensus on statements (predefined as ≥70% agreement). An international panel of 40 experts achieved >90% to unanimous consensus on 31 guidance statements for the recognition, diagnosis, and management of POTS and non-POTS dysautonomia.
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