If you've been diagnosed with POTS, you may have been treated as though every POTS patient is the same. Same medications. Same exercise protocol. Same advice. And if that approach hasn't worked for you, there's a reason.
POTS isn't one thing to solve. It can present in many different ways. At our clinic, we shy away from handing out labels and care more about identifying mechanisms. However, there are three primary POTS subtypes that are necessary to understand because it paints a picture that no two cases should be treated the same.
The 3 types of POTS are neuropathic, hyperadrenergic and hypovolemic. In all 3, the heart speeds up by 30 or more beats per minute when you stand to keep blood moving to the brain. The types differ in why blood pressure struggles to hold: the nerves controlling the blood vessels send weak signals, the norepinephrine response runs too hot, or blood isn't being distributed well. Our team looks for the mechanism behind the label.
What All 3 Types of POTS Have in Common
Before we break each subtype apart, here's what all three share.
In every type of POTS, the body is doing the same thing: using a racing heart to compensate for blood pressure that wants to drop when you stand up. The heart cranks up (30 or more beats per minute above your resting rate) to keep blood moving toward the brain. Blood pressure stabilizes. You stay conscious. But the cost of running that compensation constantly is what produces most of the symptoms people with POTS experience.
The difference between the three subtypes is why the blood pressure is struggling to begin with. And that “why” is everything.
Type 1: Neuropathic POTS
In neuropathic POTS, the nerves controlling blood vessel tension aren't doing their job properly.
Your blood vessels need to maintain a certain amount of tension to keep pressure stable when you stand up. Think of it like holding your thumb over a garden hose to keep the water pressure high. In neuropathic POTS, the grip isn't strong enough. The vessels can't hold that tension, pressure starts to drop, and the heart has to step in to compensate.
The underlying problem here is nerve signaling. The vessels aren't getting the right instructions to stay firm when you move upright.
Type 2: Hyperadrenergic POTS
This is the subtype that tends to produce the most intense and confusing symptoms, and the one most likely to be mistaken for an anxiety disorder.
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In hyperadrenergic POTS, the compensation loop runs too hot. To signal the heart to beat faster, your body releases norepinephrine, the chemical messenger of your sympathetic nervous system. Normally this happens in a controlled burst. In hyperadrenergic POTS, because the blood pressure problem keeps feeding the signal, norepinephrine floods the system and stays elevated.
High norepinephrine produces symptoms of its own: sweating, feeling hot, palpitations, a wired and shaky feeling, elevated anxiety. These aren't a separate problem or a sign that something psychological is happening. They're the direct and predictable result of your nervous system working at maximum capacity just to keep you upright.
Type 3: Hypovolemic POTS
This one is a little more subtle. The issue here isn't nerve signaling or an overactive stress response. It's about how blood is being distributed throughout the body.
Think of it less as a pressure problem and more as an allocation problem. Your brain isn't getting its share of blood flow, not necessarily because there isn't enough blood, but because the system controlling where it goes isn't directing it effectively. Blood pools or distributes unevenly, the brain gets shortchanged, and the heart compensates.
How Do You Know Which Type of POTS You Have?
None of this can be determined from a standard tilt table test alone. Understanding which mechanism is driving your POTS requires looking at cerebral blood flow, CO2 levels, heart rate, and blood pressure together, and watching how they interact as you move through different positions.
That's the only way to know what you're actually dealing with. And knowing is where treatment that works begins.
Frequently Asked Questions
What are the three types of POTS?
The three recognized subtypes of POTS are neuropathic POTS (nerve signaling to blood vessels is impaired), hyperadrenergic POTS (the sympathetic compensation loop runs too hot, flooding the system with norepinephrine), and hypovolemic POTS (blood distribution is uneven and the brain doesn't receive its adequate share). Each subtype points to a different underlying mechanism and requires a different treatment approach.
What is neuropathic POTS?
In neuropathic POTS, the nerves controlling blood vessel tension aren't functioning properly. Blood vessels can't maintain enough pressure when you stand, so the heart compensates with a higher rate. Think of it like a garden hose where the grip isn't strong enough to maintain pressure. The vessels can't hold their tension, and the heart has to step in.
What is hyperadrenergic POTS?
Hyperadrenergic POTS is the subtype most likely to be mistaken for an anxiety disorder. The body's compensation loop runs too hot. To signal the heart to beat faster, norepinephrine floods the system and stays elevated. High norepinephrine produces its own symptoms: sweating, feeling hot, palpitations, wired and shaky feeling, elevated anxiety. These aren't psychological. They're the direct result of the nervous system working at maximum capacity to keep you upright.
What is hypovolemic POTS?
In hypovolemic POTS, the issue is blood distribution rather than nerve signaling or an overactive stress response. The brain isn't getting its share of blood flow, not necessarily because there isn't enough blood, but because the system controlling where it goes isn't directing it effectively. Blood pools or distributes unevenly, the brain gets shortchanged, and the heart compensates.
How do you determine which type of POTS you have?
POTS subtype cannot be determined from a standard tilt table test alone. Understanding which mechanism is driving your POTS requires measuring cerebral blood flow (via transcranial Doppler), CO2 levels, heart rate, and blood pressure together while watching how they interact as you move through different positions. Only then can you identify the actual upstream cause and target the right treatment.
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