Tilt Testing in POTS : Safe and Effective Options

Dr Graham Exelby September 2025. This is a personal opinion and may differ from that of your medical advisers.

Introduction

Many centres continue to employ the tilt tests to assess autonomic dysfunction, especially in POTS and Long COVID.    We advise against this, preferring a combination of NASA lean tests, which may be done as often as needed to secure a diagnosis, and from clinic a supine and standing echocardiogram which provides more information on what is happening, than in the other tests.    This at present is done in only 1 specialized echocardiography centre in Brisbane, and this combination I believe provides a safer option that afforded by tilt testing.  

1. Tilt Table Test

• What it does: Tilts the patient upright while strapped to a table.

• Measures: Heart rate and blood pressure.

• Limitations:

  • Does not show what happens inside the heart.

  • Often makes symptoms worse for days or weeks.

  • Less useful for guiding treatment.

2. NASA Lean Test

• What it does: Simple bedside test — patient stands upright, leaning against a wall, for 10 minutes.

• Measures: Heart rate and blood pressure changes.

• Strengths:

  • Safe, quick, no special equipment.

  • Can be repeated as symptoms fluctuate.

  • Shows typical heart rate rise in POTS.

• Limitations:

  • Does not show detailed changes in heart filling.

3. Supine–Standing Echocardiography

• What it does: Ultrasound of the heart lying down, then repeated standing.

• Measures:

  • How much blood fills the heart (preload).

  • How strongly the heart pumps (ejection fraction).

  • Stroke volume and blood flow changes.

• Strengths:

  • Identifies preload failure — the heart not filling properly when upright.

  • Explains dizziness, fatigue, and “brain fog.”

  • Distinguishes filling problems from outflow or valve disease.

• Limitations:

  • Only funded every 2 years under current rules, so must be used strategically.

Why I Prefer NASA Lean + Supine–Standing Echo

• Both tests are safe and repeatable.

• Together, they give a clear picture of the problem:

  • NASA Lean shows the heart rate/BP changes.

  • Echo shows the filling and pumping changes.

• This combination avoids the risks of tilt testing and provides the strongest guidance for diagnosis and treatment.