Key result
Older age correlates with lower orthostatic delta heart rate without worsening autonomic symptoms or quality of life.
Why the study?
Although orthostatic tachycardia regresses with age in healthy individuals, POTS diagnostic criteria use a single delta heart rate cut-off of 30 bpm for adults >19 years, potentially causing delayed or misdiagnosis. The relationships between age, delta heart rate, autonomic symptom burden, and quality of life in orthostatic intolerance required exploration.
Observational (n=735)
In patients with orthostatic intolerance, aging is associated with a decrease in orthostatic tachycardia and orthostatic intolerance symptoms without a reduction in overall autonomic symptom burden or quality-of-life impairment, suggesting that current heart rate thresholds for diagnosing POTS in older adults may require re-evaluation.
Age-associated decline in orthostatic tachycardia despite unchanged symptom burden; leaves open whether age-adjusted POTS thresholds merit prospective validation.
Background/Introduction In healthy individuals, others have shown a regression in orthostatic tachycardia with ageing. Yet, the orthostatic Delta heart rate (DHR) criterion used for those with Postural Orthostatic Tachycardia Syndrome (POTS) only has a cut-off of 30bpm for those >19 years old and 40bpm for those ≤19 years old. This may result in delayed or misdiagnosis of this debilitating condition. Purpose To explore the relationship between age and DHR, autonomic symptom burden and health-related quality-of-life (HrQoL) in individuals with orthostatic intolerance (OI). Methods This is a retrospective analysis of consecutive participants with symptoms of OI, referred for autonomic assessment between May-2021 and June-2024. Autonomic symptom burden and HrQoL were established via the Composite Autonomic Symptom Score [COMPASS-31; six domains: OI, vasomotor, secretomotor, gastrointestinal, bladder and pupillomotor], and the EuroQoL Visual Analogue Scale (EQ-VAS). DHR was determined via a 10-minute Active Stand Test, conducted as per international consensus. Correlations between age, and autonomic symptom burden, HrQoL and DHR were determined using Pearson’s or Spearman’s tests as appropriate. Results A total of 735 participants with OI were included [89.4% female; median age 30 (IQR 22–40) years; median DHR 32 (IQR 23–42)bpm; 79.5% POTS]. There was a negative correlation between age and DHR (r = -0.29, p < 0.001; Figure 1), indicating a decrease in orthostatic tachycardia with age. However, there was no significant correlation between age and overall autonomic symptom burden (Total COMPASS-31; r = -0.06, p = 0.13; Figure 2A). Interestingly, when the COMPASS-31 subdomain scores were evaluated, increasing age was found to correlate with lower burden of OI (r = -0.18, p < 0.001) and vasomotor (r = -0.12, p = 0.001) symptoms; but higher burden of bladder symptoms (r = 0.13, p < 0.001), with no significant correlation with secretomotor, gastrointestinal or pupillomotor symptoms (all p > 0.05). There was no evidence of a linear relationship between age and HrQoL (r = -0.01, p = 0.79; Figure 2B). Conclusion/ Discussion In a cohort of participants with OI, ageing was associated with a reduction in symptoms of OI and orthostatic tachycardia. While autonomic symptoms may manifest differently with ageing, there was no correlation between age and overall autonomic symptom burden or HrQoL. This data highlights the nuances of using DHR criterion in the evaluation and management of those with OI. A re-evaluation of the heart rate threshold for POTS diagnosis in older individuals may be warranted. Further research is needed to incorporate use of validated patient-reported outcome measures for broader autonomic assessment in addition to orthostatic testing for improved diagnosis and management of this complex syndrome.
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Wilson et al. (2026) conducted an observational in Orthostatic intolerance (OI) (n=735). Increasing age was evaluated on Correlation between age and orthostatic delta heart rate (DHR), autonomic symptom burden (COMPASS-31), and health-related quality-of-life (EQ-VAS) (r = -0.29 (for DHR), p=< 0.001). Increasing age correlated with decreased orthostatic delta heart rate (r=-0.29, p<0.001), but not with overall autonomic symptom burden (r=-0.06, p=0.13) or quality of life (r=-0.01, p=0.79).
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