Tilt Table, Active Stand, or NASA Lean?
Three different orthostatic tests are used to diagnose POTS. They are not interchangeable. Understanding what each does — and what each doesn't do — matters.
You do not need a referral from your doctor. Request an appointment online in about two minutes, and we will call you to arrange a time. Testing takes 40–60 minutes.
Request an appointment →Please note the tests themselves are not covered by a Medicare rebate. Questions? Call 02 9388 0615.
What All Three Tests Have in Common
All three tests provoke the postural change that defines POTS. The patient lies down quietly for a baseline, then assumes an upright posture (tilted, standing, or leaning). Heart rate and blood pressure are recorded continuously or at frequent intervals over 10 minutes. The diagnostic finding for POTS is a sustained heart rate rise of ≥30 beats per minute (40 bpm in adolescents) within 10 minutes of upright posture, without a significant blood pressure drop, in association with symptoms.
The differences between the tests matter for sensitivity, practicality and clinical context.
The Three Tests
1. Tilt Table TestGold Standard
- How it works
- Patient is strapped to a motorised table that tilts from horizontal to ~70° head-up. The patient remains passive (no leg muscle pump activity). Beat-to-beat heart rate and continuous blood pressure are recorded throughout.
- Duration
- 10–45 minutes upright depending on protocol. Often combined with pharmacological provocation (e.g. isoprenaline, nitrate) when investigating syncope.
- Sensitivity for POTS
- Highest of the three — passive standing removes the muscle pump contribution and amplifies orthostatic stress. Captures more subtle POTS that may not show on active stand.
- Strengths
- Most sensitive. Reproducible protocol. Useful for evaluating vasovagal syncope, orthostatic hypotension, and POTS simultaneously. Can capture vasodepressor and cardioinhibitory responses.
- Limitations
- Requires specialised equipment. Patient is strapped to the table (unsettling for some). Cost and access barriers. May produce false positives (especially in young women).
- Where used
- Tertiary autonomic labs, cardiac electrophysiology centres, dedicated autonomic clinics.
2. Active Stand TestPractical Default
- How it works
- Patient lies supine for at least 10 minutes (baseline). Then stands actively from supine to upright posture. Heart rate and blood pressure recorded supine, then at 1, 3, 5, 7, and 10 minutes of standing (or continuously where equipment allows).
- Duration
- 20 minutes total (10 supine baseline + 10 standing).
- Sensitivity for POTS
- Good but slightly less sensitive than tilt — active standing engages the muscle pump, which partly offsets venous pooling and may mask milder POTS.
- Strengths
- No specialised tilt table required. Reproducible. Easy to combine with comprehensive autonomic testing (HRV, Valsalva, deep breathing) in a single session. Real-world relevance — active standing is what patients do all day.
- Limitations
- Slightly lower sensitivity than tilt. Requires continuous or frequent recording for accurate diagnosis.
- Where used
- Most outpatient autonomic clinics, including ours. The pragmatic balance of sensitivity and feasibility.
3. NASA 10-Minute Lean TestField/Telehealth Option
- How it works
- Patient lies supine for 5 minutes (baseline). Stands and leans back against a wall (heels ~15 cm from the wall, head and shoulders touching). Heart rate and blood pressure recorded supine, then at 1, 3, 5, 7, and 10 minutes of lean.
- Duration
- 15 minutes total.
- Sensitivity for POTS
- Approaches that of active stand for POTS detection. Slightly more provocative than free standing because the wall reduces leg muscle pump.
- Strengths
- Can be done anywhere — no equipment beyond a sphygmomanometer and stopwatch. Increasingly used in post-COVID dysautonomia screening, where high test volume and equipment-light protocols are advantageous. Can be patient-administered in telehealth setting with prior training.
- Limitations
- Without continuous beat-to-beat BP monitoring, subtle hypotension may be missed. Patient effort affects reproducibility. Less validated in classical autonomic syndromes than tilt or active stand.
- Where used
- Post-COVID clinics, screening contexts, telehealth/remote settings. Not a substitute for full autonomic testing when POTS is confirmed.
Side-by-Side Comparison
| Feature | Tilt Table | Active Stand | NASA Lean |
|---|---|---|---|
| Sensitivity for POTS | Highest | High | Moderate–High |
| Equipment required | Motorised tilt table, continuous BP monitor | BP monitor (continuous ideal), HR monitor | Sphygmomanometer, stopwatch |
| Patient activity | Passive (strapped) | Active standing | Active lean against wall |
| Duration upright | 10–45 min | 10 min | 10 min |
| Useful for syncope evaluation | Yes — gold standard | Limited | No |
| Useful for orthostatic hypotension | Yes | Yes | Limited |
| Combines with autonomic battery | Yes | Yes (most efficient) | No (standalone) |
| Setting | Specialised lab | Outpatient clinic | Office, clinic, or telehealth |
Which Test Do We Use?
Our method: a comprehensive autonomic battery built around the active stand test
Our clinic does not use a tilt table. For every patient we use the active stand test with recovery blood pressure within a comprehensive autonomic battery that also includes heart rate variability (deep breathing), the Valsalva manoeuvre, the isometric handgrip test, and SudoScan — all done in a single visit. This combination gives a complete mechanistic picture and identifies POTS subtype. If a passive tilt table study is ever required, it is arranged separately through a hospital autonomic or electrophysiology service.
For patients whose POTS is suspected but not confirmed on active stand — particularly where pre-syncopal or syncopal symptoms predominate — formal tilt table testing is the next step. We coordinate this with cardiology when needed.
For post-COVID dysautonomia screening, the NASA Lean is useful as a triage tool. Where the screen is positive, comprehensive testing follows.
Why This Matters for Patients
If you have been told your "tilt test was normal" but your symptoms strongly suggest POTS, it may be worth seeking comprehensive autonomic testing. Reasons for false-negative tilt include: timing of menstrual cycle (volume status varies); recent salt or fluid loading; recent rest; protocol variations between labs; and conditions like hyperadrenergic POTS where the diagnostic features are different.
Conversely, if you have been told you have POTS based on a simple "stand up and take pulse" test without proper continuous recording, the diagnosis may not be as solid as it appears — and a full autonomic assessment is worth seeking before committing to long-term treatment.
Comprehensive Autonomic Testing in a Single Visit
Active stand + HRV + Valsalva + handgrip + SudoScan, in one appointment, with results within a week.
Book POTS TestingBook Your POTS Test Today
Stop waiting years for answers. Fill out the form below and we'll contact you to schedule your appointment. Get tested and receive your results within one week.
Thank you for getting in touch!
One of our colleagues will get back to you shortly.
Have a great day!