Medical Disclaimer: This article is for educational and informational purposes only and does not constitute medical advice. Traditional Chinese Medicine (TCM) approaches described herein should be pursued only under the guidance of qualified, licensed practitioners. POTS is a complex medical condition requiring proper diagnosis and management by a physician. Nothing in this article should be construed as a substitute for professional medical evaluation or treatment.

Yoon Hang Kim, MD, MPH

Board-Certified inPreventive Medicine |

Osher Fellow University of Arizona Integrative Medicine Fellowship |

Direct Integrative Care — www.directintegrativecare.com

Traditional Chinese Medicine Approaches to Postural Orthostatic Tachycardia Syndrome (POTS): Bridging Ancient Frameworks and Modern Autonomic Science

Introduction

Postural orthostatic tachycardia syndrome (POTS) is one of the most common forms of dysautonomia, affecting an estimated one to three million Americans, predominantly women of childbearing age [1,2]. Defined by an excessive heart rate increase of 30 beats per minute or more within ten minutes of standing—without accompanying orthostatic hypotension—POTS produces a constellation of symptoms that can be profoundly disabling: dizziness, palpitations, fatigue, brain fog, gastrointestinal dysmotility, exercise intolerance, and thermoregulatory disturbance [1,3].

Standard biomedical management rests on volume expansion (high fluid and salt intake), graded exercise reconditioning, compression garments, and pharmacotherapy with agents such as beta-blockers, fludrocortisone, midodrine, or ivabradine [1,3]. While these strategies help many patients, a significant proportion remain symptomatic, and the multisystem nature of the disorder invites integrative approaches. Traditional Chinese Medicine (TCM)—particularly acupuncture and Chinese herbal medicine—offers a complementary framework that has been used to address dysautonomia-like presentations for millennia.

This article explores the TCM pathophysiology of POTS, the classical pattern differentiations most relevant to modern dysautonomia phenotypes, and the emerging evidence base for acupuncture and related interventions in autonomic regulation.

Core TCM Pathophysiology of POTS

Qi and Blood Disharmony

In TCM theory, the cardinal symptoms of POTS—tachycardia, dizziness, fatigue, and cognitive clouding—are interpreted as a failure of Qi to adequately propel Blood to the upper body upon assuming an upright posture. The classical concept is that “clear Yang fails to reach the head,” resulting in dizziness, blurred vision, and impaired cognition, while the Heart Spirit (Shen) becomes disturbed, manifesting as palpitations, anxiety, and insomnia [4,5]. This framework maps remarkably well onto the cerebral hypoperfusion and sympathovagal imbalance documented in POTS by modern hemodynamic studies [6].

The Heart–Spleen–Kidney Axis

TCM localizes POTS pathology along a three-organ axis that governs circulation, fluid regulation, and autonomic stability:

Heart (Xin): The Heart governs Blood circulation and houses the Shen. Palpitations, anxiety, and insomnia in POTS are attributed to Heart Qi or Heart Blood deficiency, and in hyperadrenergic phenotypes, to Heart Yin deficiency with deficiency-heat [4,5].

Spleen (Pi): The Spleen governs transformation and transport of nutrients and fluids. Chronic fatigue, gastrointestinal dysmotility, orthostatic intolerance, and the tendency toward hypovolemia point to Spleen Qi deficiency—the Spleen failing to generate adequate Blood and to hold fluids within the vessels. In classical TCM, the Spleen is regarded as the “Sea of Qi and Blood” and the root of postnatal Essence [7,8].

Kidney (Shen): The Kidney stores Essence (Jing) and governs water metabolism. Chronic, post-viral, or post-stress POTS—including post-COVID presentations—maps onto Kidney Yin and Yang depletion with poor fluid regulation and autonomic instability [4,9]. The Kidney’s role in anchoring Yang Qi is thought to underlie orthostatic tolerance.

Common TCM Patterns Encountered in POTS

POTS patients frequently present with mixed patterns, and individualized pattern differentiation (bian zheng) remains essential. The following are the patterns most consistently described in TCM literature on dysautonomia:

Heart–Spleen Qi Deficiency: Dizziness on standing, palpitations, fatigue, poor appetite, loose stools, easy bruising, and anxiety. This is perhaps the most common pattern seen in the hypovolemic POTS phenotype and corresponds closely to the Gui Pi Tang (Restore the Spleen Decoction) presentation described since the Song Dynasty [7,8,10].

Qi and Blood Deficiency with Blood Stasis: Marked fatigue, orthostatic symptoms, cold extremities with possible purple discoloration of the dependent legs upon standing, headaches, and cognitive slowing. The acrocyanosis and blood pooling seen clinically in many POTS patients is conceptualized as Blood stasis superimposed on deficiency [4,11].

Yin–Yang Disharmony (Kidney–Heart): Tachycardia with night sweats, insomnia, anxiety, heat or cold intolerance, and variable blood pressure. This pattern is particularly relevant to the hyperadrenergic POTS phenotype and to patients with disrupted Kidney–Heart communication, where Kidney Water fails to cool Heart Fire [4,5].

Ying–Wei (Nutritive–Defensive Qi) Disharmony: The Huang Di Nei Jing, composed around 100 BCE, describes a syndrome of alternating chills and fever, palpitations, gastrointestinal dysfunction, insomnia, and anxiety that has been retrospectively mapped onto modern dysautonomia presentations [12,13]. In this framework, Ying (Nutritive) Qi—active during rest and sleep for organ repair—and Wei (Defensive) Qi—active during waking hours for immune and thermoregulatory functions—become dysregulated. The Wei Qi remains perpetually activated while the Ying Qi cannot circulate adequately at night, producing a pattern strikingly analogous to the sympathetic overdrive and impaired parasympathetic recovery seen in POTS [12,13].

Main Treatment Principles

Tonify Qi and Blood: Strengthen Spleen and Heart function to improve central blood volume, cerebral perfusion, and cognitive function. This principle parallels the biomedical emphasis on volume expansion and electrolyte support [4,7].

Regulate and Anchor Heart Qi: Calm palpitations, reduce sympathetic overactivity, and stabilize the Shen. This addresses the tachycardia and anxiety components of POTS [4,5].

Nourish Yin and Support Yang: In chronic, post-infectious, and long-COVID POTS, treatment strategies focus on replenishing Yin and Essence while gently supporting Yang to restore orthostatic tolerance [4,9].

Harmonize Ying and Wei: Stabilize autonomic responses, thermoregulation, and sweating by rebalancing nutritive and defensive Qi—a principle with no direct Western equivalent but with clear physiologic correlates in sympathovagal balance [12,13].

Acupuncture for Autonomic Regulation in POTS

The evidence base for acupuncture’s effects on autonomic nervous system function has grown considerably. A 2022 systematic review and meta-analysis of nine randomized controlled trials by Hamvas et al., published in Complementary Therapies in Medicine, found that verum acupuncture significantly increased high-frequency heart rate variability (HF-HRV, a marker of parasympathetic tone) and reduced the low-frequency to high-frequency ratio (LF/HF, indicating reduced sympathetic dominance) compared to sham acupuncture [14]. A 2025 Frontiers in Neuroscience meta-analysis of 10 RCTs involving 744 patients confirmed acupuncture’s bidirectional modulatory capacity on autonomic function, with significant improvements in standard deviation of normal-to-normal intervals (SDNN), HF, and LF/HF parameters [15].

While large-scale POTS-specific RCTs remain limited, recent clinical pearl publications in Medical Acupuncture (2025) by Sari, Jin, and colleagues report case series demonstrating improvement in dizziness, palpitations, and postural heart rate increments beginning as early as the first acupuncture session, with progressive benefit through course-based protocols [16,17]. An earlier case report by Boyle (2021) documented acupuncture combined with lifestyle modification for POTS management [18].

The proposed mechanisms include activation of afferent nerve fibers projecting to the nucleus tractus solitarius (NTS) and vagal nuclei in the brainstem, engagement of the cholinergic anti-inflammatory pathway, hypothalamic modulation of the HPA axis, and local effects on microcirculation [14,15,19].

Frequently Cited Acupuncture Point Strategies

Point selection is always guided by pattern differentiation. Commonly described protocols for POTS-like presentations include the following strategies, which should be individualized based on the patient’s TCM pattern:

Tonify Qi and Blood: ST36 (Zusanli), SP6 (Sanyinjiao), CV6 (Qihai), CV4 (Guanyuan), BL20 (Pishu), BL21 (Weishu), BL17 (Geshu) [4,16,17].

Regulate Heart and Calm Shen: PC6 (Neiguan), HT7 (Shenmen), CV14 (Juque), CV17 (Shanzhong), Anmian [4,14,16]. PC6 and HT7 have the strongest evidence base for modulating sympathovagal balance and reducing heart rate in controlled studies [14,20].

Support Kidney: KI3 (Taixi), KI6 (Zhaohai), BL23 (Shenshu), DU4 (Mingmen) [4].

Harmonize Ying–Wei and Upper Circulation: LI4 (Hegu), LU9 (Taiyuan), DU20 (Baihui), GB20 (Fengchi) [4,12]. DU20 is classically indicated for “raising clear Yang to the head” and is frequently used for orthostatic dizziness.

Chinese Herbal Medicine Concepts

Chinese herbal formulas for POTS-like presentations are always individualized by pattern, but several classical formula families are relevant:

Heart–Spleen Deficiency: The Gui Pi Tang (Restore the Spleen Decoction) family, originating from Yan Yonghe’s Ji Sheng Fang (1253 CE), is the classical formula for concurrent Spleen Qi and Heart Blood deficiency. Its constituent herbs—including Ren Shen (Ginseng), Huang Qi (Astragalus), Dang Gui (Angelica), Suan Zao Ren (Ziziphus), and Long Yan Rou (Longan)—tonify Qi, nourish Blood, and calm the Shen. Modified versions are widely used in clinical practice for fatigue, palpitations, insomnia, poor memory, and anxiety [7,8,10].

Yin-Deficient, Hyperadrenergic Presentations: Modified Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill) patterns are used to nourish Kidney Yin and clear deficiency-heat in patients presenting with tachycardia, night sweats, heat intolerance, and anxiety [4,5].

Kidney–Heart Disharmony: Formulas that support the communication between Kidney Water and Heart Fire—addressing insomnia, palpitations, and anxiety with Yin-nourishing and Shen-calming strategies [4,5].

Given the polypharmacy and hemodynamic lability common in POTS, the literature consistently stresses careful herbal–drug interaction review and gradual dosing under a trained herbalist. This is especially important for patients on beta-blockers, fludrocortisone, midodrine, or anticoagulants [4,21].

Lifestyle and Adjunctive TCM Strategies

Diet to Support Qi and Blood: TCM dietary guidance for POTS patients emphasizes warm, cooked foods; adequate protein; iron-rich and deeply colored vegetables; and avoidance of excessive cold or raw foods, which in classical theory further weaken the Spleen’s transformative function. This aligns well with biomedical nutritional counseling for POTS [4].

Fluid and Salt: TCM-oriented clinicians typically incorporate the standard biomedical recommendation of generous fluid and salt intake, reframing it as supporting Qi and Blood volume and Spleen function [1,3,4].

Tai Chi and Qi Gong: These mind-body practices are particularly well suited for POTS patients, who often cannot tolerate conventional upright exercise. A 2020 review by Yeung et al. found that the slow movements and breath coordination in Tai Chi and Qi Gong alter autonomic balance toward parasympathetic dominance, attenuate HPA-axis reactivity, and gently condition the cardiovascular system [22]. For POTS patients, the ability to perform these practices seated and to gradually progress to standing makes them an accessible entry point for physical reconditioning [23,24].

Compression and Graded Exercise: Standard POTS interventions such as compression garments and graduated exercise programs are readily incorporated into TCM management and reframed as external aids to assist Qi and Blood ascent and prevent stagnation in the lower Jiao [1,3].

Integration With Biomedicine

TCM approaches to POTS are best understood as adjunctive to—not replacements for—standard biomedical management. Volume expansion, physical reconditioning, and appropriate pharmacotherapy remain foundational. What TCM adds is a complementary framework for understanding the multisystem nature of the disorder and additional therapeutic tools, particularly acupuncture’s documented effects on autonomic balance [14,15].

For the integrative clinician, thinking in parallel—mapping POTS subtypes (neuropathic, hypovolemic, hyperadrenergic) onto specific TCM organ-network patterns—can help tailor acupuncture and herbal interventions to the individual patient. A hyperadrenergic POTS patient with tachycardia, night sweats, and anxiety suggests Kidney–Heart Yin deficiency and warrants a different acupuncture and herbal strategy than a hypovolemic patient with fatigue, loose stools, and blood pooling, who presents as Heart–Spleen Qi deficiency [4,16].

The current evidence supports acupuncture as a safe, well-tolerated modality with plausible mechanisms for autonomic modulation. Rigorous, large-scale randomized controlled trials specifically targeting POTS populations are needed to advance this field from promising preliminary data to definitive clinical guidance [14,15,16].

References

1. Sebastian SA, Co EL, Panthangi V, et al. Postural orthostatic tachycardia syndrome (POTS): an update for clinical practice. Curr Probl Cardiol. 2022;47(12):101384.

2. Zhao S, Tran VH. Postural Orthostatic Tachycardia Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.

3. Sheldon RS, Grubb BP, Olshansky B, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41–e63.

4. Maciocia G. The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists. 3rd ed. Edinburgh: Churchill Livingstone/Elsevier; 2015.

5. Bensky D, Barolet R. Chinese Herbal Medicine: Formulas & Strategies. 2nd ed. Seattle: Eastland Press; 2009.

6. Angeli AM, Salonen BR, Ganesh R, et al. Symptom presentation by phenotype of postural orthostatic tachycardia syndrome. Sci Rep. 2024;14(1):205.

7. Gui Pi Tang (Restore the Spleen Decoction). Ji Sheng Fang (Formulas to Aid the Living), Yan Yonghe, 1253 CE. Reviewed in: Bensky D, Barolet R, eds. Chinese Herbal Medicine: Formulas & Strategies. Eastland Press.

8. Chen J, Chen T. Chinese Herbal Formulas and Applications. Art of Medicine Press; 2009.

9. Blitshteyn S. Postural orthostatic tachycardia syndrome and other autonomic disorders after COVID-19 infection: a case series of 20 patients. Immunol Res. 2021;69(2):225–234.

10. Yeung WF, Chung KF, Poon MM, et al. Prescription of Chinese herbal medicine in pattern-based traditional Chinese medicine treatment for depression: a systematic review. Evid Based Complement Alternat Med. 2015;2015:160189.

11. Kaptchuk TJ. The Web That Has No Weaver: Understanding Chinese Medicine. 2nd ed. New York: McGraw-Hill; 2000.

12. Wolf AA. Dysautonomia: historical perspectives from Chinese medicine. The Brain Health Magazine. 2020.

13. Huang Di Nei Jing (The Yellow Emperor’s Classic of Internal Medicine). Compiled ca. 100 BCE. Translation: Unschuld PU, Tessenow H. Huang Di Nei Jing Su Wen. University of California Press; 2011.

14. Hamvas S, Hegyi P, Kiss S, et al. Acupuncture increases parasympathetic tone, modulating HRV – systematic review and meta-analysis. Complement Ther Med. 2023;72:102905.

15. Frontiers in Neuroscience. Clinical efficacy and safety of acupuncture in modulating autonomic nervous function: a meta-analysis of randomized controlled trials. Front Neurosci. 2025;19:1694110.

16. Sari RK, Ellen E, Mihardja H. Acupuncture therapy in postural orthostatic tachycardia syndrome (POTS). Medical Acupuncture. 2025. doi:10.1177/19336586251384668.

17. Jin P, et al. Management of postural orthostatic tachycardia syndrome through acupuncture and Chinese herbs. Medical Acupuncture. 2025. doi:10.1177/19336586251383274.

18. Boyle K. Acupuncture and lifestyle modification for postural orthostatic tachycardia syndrome: a case report. Journal of Chinese Medicine. 2021;1(127).

19. Li QQ, Shi GX, Xu Q, et al. Acupuncture effect and central autonomic regulation. Evid Based Complement Alternat Med. 2013;2013:267959.

20. Chung JW, Yan VC, Zhang H. Effect of acupuncture on heart rate variability: a systematic review. Evid Based Complement Alternat Med. 2014;2014:819871.

21. Liu C, Huang Y. Chinese herbal medicine on cardiovascular diseases and the mechanisms of action. Front Pharmacol. 2016;7:469.

22. Yeung A, Chan JSM, Cheung JC, Zou L. Qigong and Tai-Chi for mood regulation. Focus (Am Psychiatr Publ). 2018;16(1):40–47.

23. Fu Q, Levine BD. Exercise in the postural orthostatic tachycardia syndrome. Auton Neurosci. 2015;188:86–89.

24. Blitshteyn S, Chopra P. Exercise in postural orthostatic tachycardia syndrome: focus on individualized exercise approach. J Clin Med. 2024;13(22):6922.